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Colorectal surgeons have focused on the lateral structure of rectum for a long time and lateral ligament is the common term to depict this structure. A better understanding of lateral rectal structure could be beneficial to performing the total mesorectum excision (TME) procedure and protecting patients' urinary, sexual and defecation function. The main controversies focus on two aspects: (1) Does the lateral ligament exist? (2) What dose it contain? Does the middle rectal artery exist? Up to now, anatomic studies have failed to reach consensus on the lateral rectal structure. However, surgeons do find the lateral rectal ligament during surgery and it may be the pathway for lateral lymph node metastasis in rectal cancer. The lateral rectal structure contains the middle rectal artery, nerve branches, lymphatics and adipose fibrous tissue around them. We summarize our clinical experience and conclude that the middle rectal artery appears in lateral ligament constantly but some of them are too small to be easily observed. Therefore, regarding the perspective of membrane anatomy, embryology and surgery, this structure may be more appropriate to be called the "lateral mesorectum". We propose this new term based on the previous literature and our own experience for the readers' reference.

A 51-year-old woman presented to the emergency room with upper abdominal pain and elevated infection parameters. No abnormalities were found during gastroscopy. A CT scan demonstrated perigastricappendagitis. Perigastricappendagitis is a rare infarction of a fatty appendix of the perigastric ligaments. It is a benign and self-limiting disease.

Fatty falciform ligament appendage torsion (F-FLAT) is a rare type of intraperitoneal focal fat infarction that involves torsion of a fatty appendage of the falciform ligament. It may cause severe pain, mimicking an acute abdomen, but is typically self-limited and does not require hospitalisation or surgery. As a type of intraperitoneal focal fat infarction, it shares many of the same physiological, clinical and radiological features of epiploic appendagitis. To our knowledge, F-FLAT has not previously been reported in a patient following a laparoscopic Roux-en-Y gastric bypass surgery. Identifying falciform ligament appendagitis is critical because it can prevent unnecessary hospitalisation, follow-up studies and surgery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Diagnosis and management of isolated syndesmotic injuries are controversial and highly debated. Hence, the aim of this study is to explore and gain the current understanding pertaining to detailed anatomy of syndesmotic ligaments through a systematic review of published cadaveric studies. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled was analyzed. Study quality was assessed based on Quality Appraisal for Cadaveric Studies (QUACS) scale. A total of 12 studies reporting 365 ankles were included in this review. Considerable inconsistency in the naming and description of syndesmotic ligaments was observed, with only 2 studies reporting the vasculature of the ligaments. Hence further investigation of the anatomy of the syndesmotic ligaments is recommended so as to better inform clinical practice, as awareness of anatomy is critical for assessment, healing, and successful surgical management. Levels of Evidence: Level III: Systematic review of anatomical dissections.

Introduction: Numerous publications have studied the regional anatomy of the carpal tunnel to define a "safe zone" to reduce the risk of perioperative neurovascular complications. This zone, located between the ulnar neurovascular bundle and the median nerve, is considered to be safe mainly because of the absence of vascular structures. This study aims to assess the presence of arterioles within this area using superb microvascular imaging (SMI)., Materials and Methods: The images from patients who underwent a bilateral routine wrist ultrasound with SMI, between January 28 and February 28, 2019, were retrospectively reviewed by two radiologists to evaluate the presence and location of arterioles in the safe zone. In addition, cadaveric wrists injected with intra-arterial red latex underwent dissection of the carpal tunnel., Results: The images from 27 patients (54 wrists) were reviewed. In the safe zone, arterioles were seen superficial to the retinaculum in 36 wrists (36/54; 66.7%) and deep to the retinaculum in 21 wrists (21/54; 38.9%). The arterioles located deep to the retinaculum were more frequently found close to the median nerve (21/54; 38.9%) than to the ulnar artery (9/54; 16.7%). In five cadaveric wrists, arterioles were detected superficial to the retinaculum in 3 wrists (3/5; 60%) and deep to the retinaculum in 2 wrists (2/5; 40%)., Conclusion: Arterioles can be seen in the safe zone both superficial and deep to the flexor retinaculum. Deep to the retinaculum, they are mainly observed in the proximal aspect of the carpal tunnel and more frequently close to the median nerve., Key Points: • Superb microvascular imaging (SMI) enables the visualization of arterioles within the "safe zone" of the carpal tunnel (visible both superficial and deep to the flexor retinaculum). • Arterioles were more frequently observed in the proximal aspect of the carpal tunnel. • Deep to the retinaculum, arterioles were more frequently seen in proximity to the median nerve.

Objective: To present the distribution of neurovascular and lymphatic vessels in uterine ligaments using 3D models based on the pathological staining of serial 2D sections of postoperative specimens., Methods: Serial transverse sections of fresh uterine ligaments from a patient with stage IB1 cervical squamous cell carcinoma were studied using the computer-assisted anatomic dissection (CAAD) technique. The sections were stained with hematoxylin and eosin, Weigert elastic fibers, D2-40 and immunostainings (sheep anti-tyrosine hydroxylase and rabbit anti-vasoactive intestinal peptide). The sections were then digitalized, registered and reconstructed three-dimensionally. Then, the 3D models were analyzed and measured., Results: The 3D models of the neurovascular and lymphatic vessels in uterine ligaments were created, depicting their precise location and distribution. The vessels were primarily located in the upper part of the ligaments model, while the pelvic autonomic nerves were primarily in the lower part; the lymphatic vessels were scattered in the uterine ligaments, without obvious regularity., Conclusion: CAAD is an effective anatomical method to study the precise distribution of neurovascular and lymphatic vessels in uterine ligaments. It can present detailed anatomical information about female pelvic autonomic innervation and the spatial relationship between nerves and vessels and may provide a better understanding of nerve-sparing radical hysterectomy.

Introduction and Hypothesis: Pelvic anatomy is complex and intimate knowledge of variabilities in anatomical relationships is critical for surgeons to safely perform surgical procedures. Three-dimensional Imaging provides the opportunity to analyze undisturbed anatomical relationships. The authors hypothesized that three-dimensional models created from pelvic computed tomography angiograms could be used to obtain vascular anatomical measurements, and that the measurements obtained from three-dimensional models would be similar to those from cadaver studies., Methods: We included all pelvic computed tomography angiograms that were acquired in female patients older than 18 years at our institution within the previous 5 years. Three-dimensional models were created using the Invivo5 software based on the Digital Imaging and Communications in Medicine files. Structures of interest were virtually dissected and measured replicating previous cadaver studies. Statistical analysis of demographics and measurements was performed., Results: The final analysis included 87 studies. The average age of the subjects was 66.9 years and their average BMI was 26.1 kg/m 2 . Of the 87 subjects, 12.6% had a history of hysterectomy, 2.3% a history of a continence procedure, and 1.1% a history of a prolapse procedure. The range of distance between the ischial spine and the pudendal artery was 3-17 mm. The closest vessels to the lower edge of the symphysis pubis were the obturator vessels. The aberrant corona mortis vessel was present in 27.9% of the subjects. Prior hysterectomy was associated with changes in the measurements of the obturator arteries with minimal changes in other measurements., Conclusions: Our results indicate that this technology provides similar measurements to those found in previous unembalmed cadaver studies. This technology offers a great opportunity to study anatomical relationships in a native undisturbed state.

Background and Aim: To investigate the prevalence, anatomy and distribution of the hepatic falciform artery (HFA) and Sappey's superior artery (SSA) using C-arm CT hepatic arteriography (C-arm CTHA)., Materials and Methods: From January 2011 to December 2012, 220 patients who underwent C-arm CTHA during initial transarterial treatment for hepatocellular carcinoma were included in this retrospective study. The HFAs and SSAs prevalence and origin were evaluated using axial images of C-arm CTHA. A 5-point scale for HFAs and a 4-point scale for SSAs were used to designate the radiologically conspicuous arteries., Results: The prevalences of the total HFAs and SSAs were 95 % (n=209) and 22 % (n=49), while those of radiologically conspicuous HFAs and SSAs were 62 % (n=137) and 10 % (n=22), respectively. Thirty HFAs (22 % of radiologically conspicuous HFAs and 14 % of the total study population) were distributed in the subcutaneous layer of the anterior abdominal wall, while the majority of SSAs ran through the superior part of the falciform ligament in the left-anterior direction and anastomosed with left inferior phrenic artery., Conclusion: Our study using C-arm CTHA revealed that the prevalence of the HFA is higher than the existing knowledge and proved the existence of the SSA radiologically for the first time., Key Points: • Prevalence of hepatic falciform artery is 95 %, higher than previously known. • 22 % of conspicious hepatic falciform arteries distributed in subcutaneous tissue around umbilicus. • The existence of Sappey's superior artery was proved with a radiological method.

Objective: To evaluate the histopathology of autonomic nerve removal within the cardinal ligaments (CLs), patients' postoperative urinary function, and the feasibility and safety of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for treatment of early-stage cervical cancer., Methods: Perioperative and postoperative parameters were compared between patients with biopsy-proven, early-stage cervical carcinoma treated with LNSRH (n = 64) versus those treated with laparoscopic radical hysterectomy (LRH, n = 42) in a retrospective study. Nerves within CLs were identified by hematoxylin-eosin staining. Rates of the following complications were compared: bladder function, sexual dysfunction, and defecation problems., Results: Duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity did not differ significantly between the LNSRH and LRH groups. Patients who underwent LNSRH had a significantly earlier return of bladder and bowel functions, with an average time to achieve residual urine of 50 mL or less of 10.22 days and a mean first defecation time of 3.58 days. Nerves were observed mainly in the CLs of the LRH group. Disease-free survival rate did not differ between the LNSRH (90.6%) and LRH (88.1%) groups (P = 0.643)., Conclusions: The LNSRH is a safe, feasible, and easy procedure for trained laparoscopic surgeons. Patients who underwent LNSRH had a more satisfactory quality of life than patients who underwent LRH.

The aim of this study was to investigate whether augmented remnant repair could enhance polyethylene terepthalate (PET) artificial ligament graft ligamentization. 12 female goats underwent ACL reconstruction with PET artificial ligament graft in the right knees. Right knees in 6 goats were reconstructed with augmented remnant repair (Remnant group), whereas the other 6 goats had no augmented remnant repair comprised the Control group. 3 goats in each group were randomly sacrificed at 6 months and 12 months respectively after surgery. The intra-articular parts of the reconstructed grafts were harvested for histological evaluation. Well-vascularized tissue ingrowth within the artificial ligament was observed in the remnant group at 12 months postoperatively. Collagen-I content of graft was significantly higher in the Remnant group than in the Control group at each time point (p<0.05). The relative expression of collagen-III positive area of the remnant-preserved group was significantly higher than that of the Control group at 12 months (p=0.005). The vascular endothelial growth factor (VEGF)-positive or CD31-positive area in the graft appeared higher in the Remnant group compared with the Control group at 6 months. Remnant repair enhanced the revascularization and remodeling of the PET artificial ligament in ACL reconstruction., (© Georg Thieme Verlag KG Stuttgart · New York.)

The use of autografts versus allografts for anterior cruciate ligament (ACL) reconstruction is controversial. The current popular options for ACL reconstruction are patellar tendon or hamstring autografts, yet advances in allograft technologies have made allogeneic grafts a favorable option for repair tissue. Despite this, the mismatched biomechanical properties and risk of osteoarthritis resulting from the current graft technologies have prompted the investigation of new tissue sources for ACL reconstruction. Previous work by our lab has demonstrated that tissue-engineered bone-ligament-bone (BLB) constructs generated from an allogeneic cell source develop structural and functional properties similar to those of native ACL and vascular and neural structures that exceed those of autologous patellar tendon grafts. In this study, we investigated the effectiveness of our tissue-engineered ligament constructs fabricated from autologous versus allogeneic cell sources. Our preliminary results demonstrate that 6 months postimplantation, our tissue-engineered auto- and allogeneic BLB grafts show similar histological and mechanical outcomes indicating that the autologous grafts are a viable option for ACL reconstruction. These data indicate that our tissue-engineered autologous ligament graft could be used in clinical situations where immune rejection and disease transmission may preclude allograft use.

Aims: The objective of our review is to provide a critical appraisal of the literature on the anatomy, structure and roles of cardinal ligaments (CL) in pelvic organ support, in conjunction with the currently evolving evidence based mainly on imaging and biomechanical modeling studies. We aim to contribute to the understanding of the pathophysiology of pelvic organ prolapse (POP) and stimulate new insights in research and development of novel surgical approaches for POP., Methods: PubMed, Embase, Scopus-Elsevier, and Cochrane Databases were searched in English and German. Studies from 1870 to 2012 were identified. The keywords used were "cardinal ligament," "transverse cervical ligament," "Mackenrodt ligament," "parametrium," and "paracervix." Cross check and Google search of the reference lists were used for missing articles., Results: We identified 35 related articles. Located at the base of the broad ligament, the CL is a supportive structure that attaches the cervix and upper vagina to the pelvic wall. The ligament contains the uterine vessels and hypogastric plexus. It conducts most of the pelvic loading forces. On MRI, it appears as a web-like structure around the axis of the internal iliac vessels. Their clinical importance is based on the apical supportive role and lymphatic-rich structure, involved in dissemination of cervical cancer., Conclusions: The structure and role of the CL have been long studied, but remained unclear. Recent studies on imaging and biomechanics have improved our understanding and provide new insights which may enable the development of new techniques in prolapse surgery., (© 2013 Wiley Periodicals, Inc.)

Objective: To determine the microvascular anatomy of the suspensory ligament of the forelimb of horses., Sample: 17 cadaveric forelimbs from 9 adult horses with no known history of forelimb lameness., Procedures: The median artery of the forelimb was cannulated proximal to the antebrachiocarpal joint and injected with contrast medium for CT evaluation of the gross vasculature (n = 2) or India ink to evaluate the microvasculature (12). Routine histologic evaluation was performed on an additional 3 forelimbs to confirm the microvascular anatomy., Results: The vascular supply of the suspensory ligament of the forelimb originated from branches of the medial and lateral palmar and palmar metacarpal vessels as well as the proximal and distal deep palmar arches. An abundant, longitudinally oriented microvascular supply was evident throughout the length of the suspensory ligament without distinct variation among the proximal, midbody, and distal regions. The intraligamentous blood supply originated from a periligamentous vascular plexus that surrounded the suspensory ligament throughout its length. Histologic findings indicated the presence of a periligamentous connective tissue plexus, which contained vessels that penetrated and anastomosed with an extensive network of intraligamentous vessels throughout the length of the suspensory ligament., Conclusions and Clinical Relevance: The suspensory ligament of the equine forelimb had an abundant intraligamentous microvascular supply throughout its entire length. The absence of an obvious hypovascular area suggested that regional variations in healing rates of the suspensory ligament are not associated with the microvascular anatomy.

Aim: This study aimed to investigate the anatomy and mechanism of pseudolesions around falciform ligament, which appeared on dynamic contrast magnetic resonance (MR) imaging., Methods: A total of 30 cases were included in the normal control group (group 1), and 30 cases were enrolled into the liver cirrhosis group (group 2). All cases underwent MR examination including in-phase and out-phase T1-weighted image, T2-weighted fat-suppressed image, and dynamic MR imaging enhancement scanning. The MR images were analyzed to detect pseudolesions, and results from the 2 groups were compared. An ultrasound examination was also performed in all cases to assess the abdominal umbilical vein blood flow., Results: In group 1, MR images detected pseudolesions in 13 cases, and signal reduction did not appear in out-phase MR images compared with in-phase MR images. In 5 of these cases, the umbilical vein was observed to be connected with the hepatic IV segment, and direction flow was toward hepatic during Doppler ultrasound examination. In the 30 patients with liver cirrhosis, pseudolesions were not detected in any of the cases, dilation of the vena epigastricas was observed in 12 cases, and flow direction was from liver. The difference in the incidence of falciform ligament pseudolesions between group 1 and group 2 was statistically significant (P > 0.01)., Conclusions: Pseudolesions around the falciform ligament are associated with the Sappey vein, and there is no significant relationship with fatty infiltration.

Aims: The uterosacral ligament (USL) contains prominent vessels, the function of which is unknown. Here we study the relationship between smooth muscle of the USL and the vascular bundles., Methods: Native samples of arteries and vascular bundles were mounted in a perfusion chamber under the stereomicroscope. The effects of noradrenalin, carbachol, oxytocin, and relaxin were monitored by digital time-lapse video and quantified by image processing., Results: Arteries were adrenergic and the smooth muscle in the adventitia cholinergic. Relaxin-2 shifted the dose response curve of noradrenalin to the right and widened the arterial lumen within 30 min. Oxytocin induced contraction of the adventitial smooth muscle leading to a slow opening of the artery. In a vascular bundle the differential pattern of both reactivities was demonstrated., Conclusions: In the USL the smooth muscle extends into the adventitial layer of blood vessels and forms a functional unit with the vascular plexus, which is regulated by relaxin and oxytocin., (Copyright © 2012 Wiley Periodicals, Inc.)

Objectives: This study evaluated histopathology and clinical outcome of autonomic nerve trauma and vessels removal within the cardinal ligament (CL) during nerve-sparing radical hysterectomy (NSRH) compared with radical hysterectomy (RH)., Methods: 25 women with FIGO stage Ib1-IIa cervical cancer underwent RH (n=13) or NSRH (n=12). Removed CLs lengths were measured. Biopsies were collected from the proximal, middle and distal segment of CLs and fixed. Different markers were used for immunohistochemisty analysis: tyrosine hydroxylase for sympathetic nerves; vasoactive intestinal polypeptide for parasympathetic nerves; CD34 for blood vessels; and D2-40 for lymphatic vessels. The volume density (Vv), a parameter of biological stereology, was used to quantitatively measure CL components, while post-operative functions, such as defecation, micturition and two-year disease free survival in RH and NSRH groups were compared., Results: The nerves mainly existed in the middle and distal segments of CLs. The Vv was greater in RH compared with NSRH for both sympathetic and parasympathetic nerve markers (P<0.05), while the Vv of blood and lymphatic vessels were same in the two groups. Average time to achieve residual urine≤50ml and first defecation were shorter in NSRH than in RH (P<0.05)., Conclusions: Less autonomic nerves within CL are transected in NSRH than in RH, while blood/lymphatic vessels are efficiently removed in both treatments. Compared to RH, NSRH decreases iatrogenic injury, which leads to reduced post-operative co-morbidities, with ensure the same radicality., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We analyzed the immunohistochemical labeling patterns of the extracellular matrix of the coracoclavicular ligaments (CCL) in order to relate the molecular composition of the attachment sites to their mechanical environment. Ligaments were exposed from 12 fresh-frozen human cadaveric samples (four males, mean age: 48.6 ± 12.1 years). Cryosection of methanol-fixed and decalcified tissue was cut and sections were labeled with a panel of monoclonal antibodies directed against collagens, proteoglycans and proteins of vascular components. Attachment sites of both ligaments showed characteristic fibrocartilaginous labeling of collagen type II, aggrecan and link protein in all samples. Labeling for type II collagen was most conspicuous at the insertion of the coracoid process. Morphometry of adjacent samples revealed a fibrocartilage zone of 10-15% in relationship with the ligament proper, where labeling for type II collagen, aggrecan and link protein was negative. The presence of fibrocartilage at both entheses of the trapezoid and conoid ligament suggests that the CCL complex is subject to shear/compression forces. A variable fibrocartilage differentiation at the entheses of both ligaments may be related to the marked change in loading and insertion angle that the ligaments undergo during shoulder movement., (© 2010 John Wiley & Sons A/S.)

Background: Right-sided ligamentum teres (RSLT) is a congenital anomaly that is sometimes encountered during hepatobiliary surgeries. However, a valid protocol for describing the segmental anatomy of livers with RSLT has not been established, and confusions or anatomic misunderstandings have been a major problem., Methods: The vascular architecture and morphological characteristics were investigated in 35 livers with RSLT using three-dimensional (3D) simulations., Results: Couinaud's four sectors and three hepatic veins were clearly distinguished in the liver with RSLT using 3D simulations. The ligamentum teres was connected with the right paramedian portal pedicle, and the long axis of the cystic fossa was always observed on the left of the ligamentum teres in all 35 livers. However, when the main portal scissura was visualized using 3D simulation, the gallbladder was always located on the border of either side of the hemilivers, and the malposition of the gallbladder was not confirmed., Conclusions: Although the right-sided components of the livers are well developed as a result of the right-dominant distribution of the feeding vessels in livers with RSLT, the basic segmental structure defined by the four sectors and the three hepatic veins are as well preserved as those in the typical liver anatomy., (© 2011 International Hepato-Pancreato-Biliary Association.)

Background: Chronic mesenteric ischemia (CMI) is a rare diagnosis for patients in their third decade of life. Other conditions can mimic the signs and symptoms of CMI, including median arcuate ligament syndrome (MALS), primary arteritides, and congenital anomalies. Here, we present the case of a 26-year-old man who presented with CMI and multivessel mesenteric occlusive disease., Methods: A 26-year-old man presented with a 6-month history of 40-pound weight loss, postprandial abdominal pain, and food fear. His physical examination showed a scaphoid abdomen with no tenderness. Findings from laboratory evaluation were normal. Computed tomography angiogram revealed celiac artery (CA) occlusion and >80% superior mesenteric artery (SMA) stenosis, with a large marginal artery of Drummond supplying collateral circulation., Results: A retroperitoneal exposure of the perivisceral aorta was performed. Surgical exposure revealed compression of both CA and SMA by the MAL. The total distance of caudal arterial displacement was >3 cm. Both the CA and SMA were chronically stenotic/occluded secondary to this compression. After division of the MAL, a retrograde aortoceliac and aortomesenteric bypass was performed for mesenteric revascularization. The patient recovered uneventfully and was discharged home on the third day after surgery tolerating a full diet., Conclusions: MALS is a pathologic entity that can affect more than the CA. This case demonstrates multivessel, mesenteric arterial insufficiency secondary to MALS sufficient to promote IMA collateralization of the SMA circulation. In young patients with CMI, multivessel MALS must be considered. In addition to MAL release, arterial revascularization may be necessary owing to stenoses from chronic compression., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Radical hysterectomy is the standard treatment for early-stage cervical cancer. Although during surgery the vessels of the cardinal ligament are divided one by one until the splanchnic nerve is identified before they are dissected, there are individual differences in the numbers of vessels. In this preliminary study, we evaluated the accuracy of preoperative detection of the vessels of the cardinal ligament by transrectal sonography with color Doppler imaging (TR-CDUS) with respect to the number of vessels detected intraoperatively., Methods: We included patients that underwent radical hysterectomy for cervical cancer in our hospital. The vessels of the cardinal ligament were detected preoperatively by TR-CDUS. Radical hysterectomy was subsequently performed and the number of vessels found at surgery was recorded., Results: A total of 21 patients were included. The median number of the left vessels detected by TR-CDUS and intraoperatively were 2 (range, 1-4) and 2 (range, 1-5), respectively. The median numbers of the right vessels detected were 3 (range, 2-4) and 3 (range, 2-4), respectively. The accuracy rates were 90.5% for the left cardinal ligament, 85.7% for the right ligament, and 81.0% for both cardinal ligaments., Conclusions: The results suggest that TR-CDUS may be useful for preoperative detection of the number of the vessels of the cardinal ligament., (Copyright © 2011 Wiley Periodicals, Inc.)

We report a case of acute abdomen caused by nontraumatic intra-abdominal bleeding in a 38-year-old man. Emergency laparotomy revealed the source of bleeding as a vein in the right colorenal ligament. The rupture of this vein may have been attributable to shear stress after severe vomiting on the day before admission. Although the patient had a coagulation disorder secondary to early-stage liver cirrhosis, there were no signs of portal hypertension intraoperatively. This report describes an unusual cause of acute hemoperitoneum, highlighting the importance of including this life-threatening disorder in the differential diagnosis of acute abdomen of unknown origin. Its outcome is dependent on early diagnosis and prompt emergency intervention.

The existence and composition of the lateral ligaments of the rectum (LLR) are still the subjects of anatomical confusion and surgical misconception up to now. Since Miles proposed abdominoperineal excision as radical surgery for rectal cancer, the identification by "hooking them on the finger" has been accepted by many surgeons with no doubt; clamping, dividing and ligating are considered to be essential procedures in mobilization of the rectum in many surgical textbooks. But in cadaveric studies, many anatomists could not find LLR described by the textbooks, and more and more surgeons also failed to find LLR during the proctectomy according to the principle of total mesorectal excision. The anatomy of LLR has diverse descriptions in literatures. According to our clinical observations, the traditional anatomical structures of LLR do exist; LLR are constant dense connective bundles which are located in either lateral side of the lower part of the rectum, run between rectal visceral fascia and pelvic parietal fascia above the levator ani, and covered by superior fascia of pelvic diaphragm. They are pathways of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes.

The incidence of ligament injury has recently been estimated at 400,000/year. The preferred treatment is reconstruction using an allograft, but outcomes are limited by donor availability, biomechanical incompatibility, and immune rejection. The creation of an engineered ligament in vitro solely from patient bone marrow stromal cells (has the potential to greatly enhance outcomes in knee reconstructions. Our laboratory has developed a scaffoldless method to engineer three-dimensional (3D) ligament and bone constructs from rat bone marrow stem cells in vitro. Coculture of these two engineered constructs results in a 3D bone-ligament-bone (BLB) construct with viable entheses, which was successfully used for medial collateral ligament (MCL) replacement in a rat model. 1 month and 2 month implantations were applied to the engineered BLBs. Implantation of 3D BLBs in a MCL replacement application demonstrated that our in vitro engineered tissues grew and remodeled quickly in vivo to an advanced phenotype and partially restored function of the knee. The explanted 3D BLB ligament region stained positively for type I collagen and elastin and was well vascularized after 1 and 2 months in vivo. Tangent moduli of the ligament portion of the 3D BLB 1 month explants increased by a factor of 2.4 over in vitro controls, to a value equivalent to those observed in 14-day-old neonatal rat MCLs. The 3D BLB 1 month explants also exhibited a functionally graded response that closely matched native MCL inhomogeneity, indicating the constructs functionally adapted in vivo.

Background: The detection rate of hepatic falciform ligament artery (FLA) has been reported as ranging from 2-25%. The rate of FLA on laparotomy, however, is reported to be higher, at 68%., Purpose: To compare the detection rate of FLA on computed tomography hepatic arteriography (CTHA) with that on angiography and dynamic CT, and to clarify the clinical significance of FLA in patients with chronic liver disease., Material and Methods: 126 consecutive patients underwent CTHA angiography and dynamic CT to evaluate suspected liver tumors. Liver function was classified as follows: normal, n=5; Child-Pugh class A, n=94; B, n=21; and C, n=6. All CT images were obtained using multidetector (MDCT) scanners (Aquilion; Toshiba, Tokyo, Japan). For CTHA, CT images were obtained during contrast material injection through the left hepatic, proper, or common hepatic artery. On CT, FLAs were retrospectively identified within the hepatic falciform ligament and the hepatic round ligament by the paging method on a workstation (TWS-5000; Toshiba, Tokyo, Japan). The detection rates were compared among the three modalities (hepatic arterial phase of dynamic CT, CTHA, and angiography). The calibers of FLA were also correlated with the hepatic function of the patients., Results: The detection rates of FLA by angiography, dynamic CT, and CTHA were 37% (47/126), 10% (13/126), and 77% (97/126), respectively. The calibers of FLA increased as the hepatic function deteriorated (P=0.001)., Conclusion: The detection rates of FLA with CTHA are far higher than those with angiography and dynamic CT. Careful interpretation with recognition of FLA on CTHA images is important, as inadvertent embolization or chemotherapeutic infusion of the FLA may result in supraumbilical skin rash.

Purpose: To determine the incidence of angiographic visualization and the clinical significance of round ligament arteries in patients who present with intractable vaginal bleeding., Materials and Methods: A review of 113 patients (age range, 20-67 years) who underwent pelvic angiography for intractable vaginal bleeding between June 1992 and May 2008 was retrospectively performed. It was recorded whether round ligament artery was visualized on pelvic aortography after uterine artery embolization (UAE). The medical records of the patients were reviewed to analyze the final clinical outcome. The Fisher exact test was used to correlate persistent vaginal bleeding after UAE with visualization of round ligament arteries., Results: Of 111 patients who underwent UAE, 42 patients (postpartum bleeding, n = 40; postabortion bleeding, n = 2) had at least one visible round ligament artery on postembolization pelvic aortography. Ten patients received round ligament artery embolization. Persistent vaginal bleeding after adequate UAE was observed more commonly in patients whose round ligament artery was seen on postembolization pelvic aortography (P = .007)., Conclusions: Round ligament arteries are commonly visualized in patients who present with postpartum bleeding and should be investigated when there is persistent bleeding, even after adequate UAE.

Study Objective: To show the relationship between the neuropeptide-Y pelvic sympathetic nerves and neoangiogenesis in the development of endometriosis, Design: Prospective study., Setting: Academic community teaching hospital., Patients: Fifteen consecutive women with unilateral endometriotic infiltration of the sacrouterine ligaments., Interventions: A laparoscopic excision/biopsy of involved and noninvolved parts of the sacrouterine ligaments were taken. The sections were incubated with the neuronal marker rabbit polyclonal anti-protein gene product 9.5 and rabbit polyclonal anti-neuropeptide-Y. We made a comparative study on the distribution of nerve fibers and their relationship to the vessels on intact and endometriotic involved tissue., Measurements and Main Results: The results show that a large amount of nerves are present around the blood vessels in the endometriosis samples, and a large number of these nerves are neuropeptide-Y sympathetic nerves. Adrenergic fibers are also present in the intact control subjects, however, in significantly smaller amounts., Conclusion: This finding shows a strong relationship between the neuropeptide-Y sympathetic pelvic nerves and the neoangiogenesis required for the development of endometriosis.

The aim of the research was histochemical and morphometric investigation of microcirculation channel and study of mastocytes in outer oblique aponeurosis stomach muscles and sacrouterine ligaments. The study was carried out on 36 patients with small pelvic organs prolapse and on 22 patients without such. Patients with different forms and severity of small pelvic organs prolapse displayed the reduction of aponeurosis microcirculatory channel, sacrouterine and round ligament of the uterus (p<0.05) in contrast to women without small pelvic organs prolapse. It was found that outer oblique aponeurosis stomach muscles in patients contains large amount of labrocytes, which degranulate with statistically significant intensiveness, in contrast to women without prolapses (p<0.05). The state of microcirculation channel and local aponeurosis secretor regulator apparatus of the outer oblique aponeurosis stomach muscles and the sacrouterine ligaments must be considered in choosing the most suitable method of suspension and fixations of small pelvic organs prolapse.

Objective: The objective of the study was to analyze the histopathologic content of the vascular portion of the cardinal ligament in patients undergoing radical hysterectomy for cervical cancer., Study Design: The vascular portion of the cardinal ligament was completely removed during radical hysterectomy. The maximum cervical diameter and length of the vascular ligament were measured on the fresh specimen. After inking, the pathologist separated and embedded the entire vascular segment from each side. Microscopic examination followed., Results: Eighty-four patients were available for analysis. The mean cervical diameter was 3.9 cm (2-8), whereas the mean vascular segment length on the right and left sides were 4 cm (1-10) and 3.8 cm (1-7), respectively. Mean number of vascular segment lymph nodes were as follows: medial right = 0.7 (0-4), medial left = 0.6 (0-5), lateral right = 0.4 (0-3), and lateral left = 0.6 (0-6). Mean diameter of medial and lateral lymph nodes were 2 mm (0.25-8) and 3.3 mm (0.25-16), respectively. The length of the vascular segment correlated inversely with maximum cervical diameter. Thirty-one percent (26 of 84) had positive pelvic side wall lymph nodes. Fourteen patients had positive vascular segment lymph nodes (1 positive = 7, more than 1 positive = 7). Three of 7 patients had bilateral positive vascular segment lymph nodes; all 7 had microscopic disease in the paravaginal soft tissue, and all 7 had positive pelvic side wall lymph nodes (6 of 7 bilateral). Including the 14 patients, a total of 19 had nodal or nonnodal microscopic disease in the vascular segment. Of these, 7 had disease in the lateral half of the vascular ligament. Histologic sectioning revealed nerve twigs and/or scattered ganglia in the vascular segment but no large nerve trunks., Conclusion: Among a population of women with high-risk, early-stage cervical cancer, the lateral vascular segment of the cardinal ligament contained metastatic disease in a substantial number of patients. This segment contains no major nerve trunks. When radical hysterectomy is chosen as primary treatment for such patients, the vascular segment of the cardinal ligament should be completely excised.

Aim: The purpose of this study was to clarify the anatomical detail of the superior group of vessels in the falciform ligament in terms of the relationship with the internal thoracic vessels, inferior phrenic vessels, and the intrahepatic portal vein., Materials and Methods: (1) Anatomical study: we dissected eight adult human cadavers (seven normal and one cirrhotic liver) to determine the relationship between the superior group of vessels in the falciform ligament, the internal thoracic vessels, and the inferior phrenic vessels. (2) Clinical study: we determined the origin and destination of the superior group of veins demonstrated in 8 of 4,006 patients with chronic liver disease who underwent the contrast enhanced CT scans., Results: (1) Anatomical study: the superior group of vessels anastomosed the right (n = 4), left (n = 2), and both (n = 2) internal thoracic vessels. They also anastomosed the left (n = 4), right (n = 1), and both (n = 2) inferior phrenic vessels. (2) Clinical study: the origin of the veins was identified as the left medial branch (n = 4), left lateral branch (n = 1), both the lateral and medial branches (n = 1), and the vein from the umbilical portion (n = 2) of the left portal vein. The drainage vein was identified as the left (n = 3), right (n = 2), and the both (n = 1) internal thoracic veins., Conclusion: We demonstrated the anastomoses between the superior group of vessels of the falciform ligament, the internal thoracic vessels, the inferior phrenic vessels, and the intrahepatic portal vein. These pre-existing anastomoses would develop as porto-systemic shunt in patients with portal hypertension.

Objective: The objective of the study was to further characterize the anatomy of the coccygeus muscle-sacrospinous ligament (C-SSL) complex and to correlate the findings with sacrospinous ligament fixations (SSLF)., Study Design: Dissections were performed in 21 female cadavers., Results: In all dissections, nerves originating from S3, S4, S5, or a combination passed over the anterior surface of the C-SSL at its midsegment, and either the pudendal or third sacral nerve coursed on the superior border of C-SSL at its midpoint. In 100% of specimens, the internal pudendal artery (IPA) passed behind or just medial to the ischial spine. The average distance of the inferior gluteal artery (IGA) from the ischial spine and the superior border of the C-SSL was 24.2 (range, 15-35) mm and 3.4 (range, 1-5) mm, respectively., Conclusion: Nerves to the coccygeus and levator ani coursed over the midportion of the C-SSL where SSLF sutures are placed. The pudendal nerve and IGA were in proximity to the superior border of the C-SSL at its midportion, whereas the IPA passed behind the ischial spine, lateral to the recommended site for suture placement.

Purpose: The aim of this study was to determine the prevalence and aberrant venous supply (inferior veins of Sappey) of hypoattenuating hepatic pseudolesions seen around the falciform ligament on portal-dominant phase multidetector computed tomography (MDCT) and the frequency of fatty infiltration of these pseudolesions on chemical-shift magnetic resonance imaging., Materials and Methods: Portal-dominant phase abdominal MDCT examinations of 728 patients were evaluated for the presence of a pseudolesion around the falciform ligament, and those with a presumed pseudolesion underwent chemical-shift magnetic resonance imaging to detect the fatty infiltration. Reconstructed MDCT images were investigated for the presence of an inferior vein of Sappey, and 30 patients without a pseudolesion were evaluated as a control group., Results: A total of 160 pseudolesions were detected around the falciform ligament in 146 (20%) patients. The longest diameter of the pseudolesions was in the craniocaudal direction in most patients (61%). An inferior vein of Sappey supplying these pseudolesions was depicted in 40 (27%) patients, and it was highly significant (P = 0.001) compared with the controls for the presence of a pseudolesion around the falciform ligament. Fatty infiltration was found in 47 (29%) patients., Conclusions: Hepatic pseudolesions around the falciform ligament are frequently encountered on portal-dominant phase MDCT images. Detection of craniocaudal extension, inferior veins of Sappey, and fatty infiltration of these pseudolesions, which were firstly described in this article, with the largest subject group based on cross-sectional imaging, might be valuable in excluding true tumors.

The authors report a rare variation, a common celiacomesenteric trunk, which was observed during routine dissection of an 89-year-old Japanese female cadaver in the laboratory of the Anatomy Department. The trunk gave rise to left gastric, common hepatic, splenic and superior mesenteric arteries. The developmental significance of this variation is discussed with a brief review of the literature.

Background: The reported pancreatic anastomosis fistula rate for pancreaticoduodenectomy, distal pancreatectomy, or enucleation is 2% to 27%. We hypothesized that reinforcement with a vascular pedicle would decrease the number of fistulas. We report a novel technique: the use of the round ligament of the liver to reinforce the pancreatic anastomosis after resection., Study Design: Patients undergoing resection from January 1, 2000 until August 8, 2005, at a tertiary referral center, were followed in a retrospective cohort study. The round ligament of the liver was disconnected from the abdominal wall, from the umbilicus to the liver. After pancreatic resection, it was sutured to the anastomosis or closure. A pancreatic fistula was defined as follows: Jackson-Pratt (JP) drainage>50 mL/d, after the fifth postoperative day, with amylase>3 times the serum level; reexploration for a fistula; postoperative pseudocyst; or death from sepsis with a presumed fistula., Results: In 95 patients, we were able to mobilize the round ligament and use it as a vascular pedicle. The overall fistula rate for the series was 5.3% (5 of 95) and for pancreaticoduodenectomy it was 8.8% (5 of 57). There were no fistulas within the distal pancreatectomy and enucleation group (n=38). Importantly, there was no mortality from pancreatic fistula in the studied patients and no need for operative intervention for a fistula., Conclusions: We present a novel technique to prevent pancreatic fistula. Although randomized trials are necessary, it appears that the use of the round ligament as a vascular pedicle for reinforcing the pancreatic anastomoses and resections results in a very low number of pancreatic fistulas.

Torsion of the free end of the falciform ligament is an extremely rare cause of localized peritonitis. A surgically proven case is presented here, with ultrasound and CT findings and a review of the published work.

Unlabelled: "Open-book" pelvic fractures associate a diastasis and/or a fracture of the pubic rami with a posterior pelvic disruption of the sacro-iliac joint. These uni or bilateral lesions are potentially lethal mainly due to associated injuries and massive pelvic hemorrhage. The most frequently injured arteries are parietal branch of the commune, internal or external arteries because of their proximity to the bone, the sacro-iliac joint and the inferior ligaments of the pelvis. The pelvic bone dislocation and the increase of pelvic volume facilitate blood effusion. The aim of this study was to determine, on a cadaver fracture model, the direct anatomical consequences of "open-book" pelvic fracture on the ilio-lumbar pedicle and the pelvic cavity volume., Materials and Methods: Bilateral open-book pelvic ring injuries were created in ten non-embalmed cadaver specimens by directly disrupting the pubic symphysis, the right and the left sacro-iliac joints. Pelvic volume was determined after total pelvic exenteration. Consequences of this fracture on vascular parietal network, nervous pelvic trunk and pelvic cavity volume were studied., Results: The mean volume of the pelvic cavity after complete visceral exenteration was 872.5 cm(3) (extremes 580-756 cm(3)). The average increase of pelvic volume was 20.8% after 5 cm of pubic diastasis. In all cases, because of a transversal disposition of the ilio-lumbar pedicle with regard to the sacro-iliac joint, reproduction of the open-book fracture caused a venous dilaceration of the ilio-lumbar vein in 12 cases after 5 cm of pubic diastasis (12/20=60%). No arterial dilaceration was observed on the ilio-lumbar artery, but this artery was put in tension., Conclusion: Open-book fractures create an increase of pelvic volume that facilitates blood diffusion from parietal pelvic vascular network. Ilio-lumbar pedicle seems to be very vulnerable in this type of fracture because of its relations to the sacro-iliac joint and its transversal disposition with regard to this joint.

The purpose of this study was to understand the clinical significance of the morphology and blood supply of the falciform ligament in laparoscopic surgery. The structure, blood vessel distribution and anastomoses of the falciform ligament were observed in 20 cases of living laparoscopy, 30 cadaveric specimens injected with latex and five cadaveric specimens with Indian ink and hyaline. The falciform ligament was formed by two sides of peritoneum and its length, largest and smallest width were 8.3+/-1.6 cm, 4.9+/-0.8 cm and 1.1+/-0.3 cm, respectively. The left inferior phrenic artery and middle segment artery of the liver formed a vessel that arched and gave off 6-12 branches to the falciform ligament. The veins of the falciform ligament drained into the left inferior phrenic vein, and were not accompanied by any artery. In conclusion, the vessels of the falciform ligament anastomose with multiple vessels and form a significant pathway of the collateral circulation in the liver. The falciform ligament is an important landmark in laparoscopic surgery.

The vascular and nerve components of ovarian ligaments (proper and suspensory) of the sheep, cow and the donkey were examined in order to investigate the presence of blood flow-regulator endovasal devices, artero-venous anastomoses, free and/or encapsulated nerve endings and ganglion cells. Both the ligaments of the investigated species showed the presence of endovasal devices (valvular apparati, intimal and polypoid cushions) and artero-venous anastomoses, the latter structurally ascribed to the first and second type of Conti and Bucciante's classification. Moreover, although not constantly, both the examined districts showed an autonomic nerve support, while four Ruffini's corpuscles were found in the suspensory ligament just in one sheep.

The purpose of this study was to trace the histological structure of the transverse ligament of the knee and its relation to the inferior lateral genicular artery. Investigations were carried out on 20 lower limbs (10 males, and 10 females) from the Department of Anatomy. It was found that close to the attachment of the transverse ligament to the menisci, bundles of fibres pass in vertical, oblique and horizontal directions, occupying a wide area on the anterior margin of the menisci. These fibres intermingle with bundles of the fibrocartilage of the menisci. In the area of the lateral attachment the inferior lateral genicular artery passes anteriorly to the transverse ligament, giving off numerous branches to the ligament. The medial part of the transverse ligament presents a thick rounded structure, surrounded by loose connective tissue. The fibres are arranged irregularly in bundles running horizontally on a tortuous course and with single spindle-like cells with darkly stained nuclei. The cells are not found at the ends of the ligament. Numerous blood vessels are observed between the bundles of fibres and on the periphery of the ligament.

Pathologic conditions of the falciform ligament leading to surgical intervention are extremely uncommon. We report a case of twisted lipomatous appendage of this ligament, demonstrated by US and CT. To our knowledge, there have been no previous reports of this entity. The extraperitoneal nature of the lesion was found by realtime sonography, but CT only was able to characterize its lipomatous nature and relationship with the falciform ligament. This lesion should be considered in the differential diagnosis of intra-abdominal focal fat infarction (IFFI), a recent vocable essentially regrouping infarction of omentum and epiploic appendages.

Background: Lesions of vascular structures are rare but serious complications of laparoscopic cholecystectomy. The purpose of this blind randomized animal study was to investigate the possibility of detecting different vascular lesions within the hepatoduodenal ligament using laparoscopic color Doppler ultrasound (LCDU)., Methods: Twenty-four lesions of the hepatic artery and portal vein were created laparoscopically in six farmer pigs using titanium clips. The following injuries were studied: (a) partial occlusion of the hepatic artery (eight cases), (b) complete occlusion of the hepatic artery (eight cases), (c) partial occlusion of the portal vein (eight cases). There were also eight cases without lesions of the vascular vessels. The order in which the injuries were created was randomly assigned. The study was performed in a blind fashion. Recognition of the injuries was attempted with LCDU., Results: All injuries were recognized correctly by LCDU. There were no false positive results. The clips were reliably located. Using color Doppler imaging, partial occlusions of the hepatic artery and portal vein were visualized by changes of the blood flow from laminar to turbulent behind the clip. Complete occlusion of the hepatic artery was recognized as a complete cessation of the colored blood flow., Conclusion: LCDU is a very efficient tool for visualizing vascular structures and evaluating the bloodstream. Partial or complete vascular occlusion by clips that may occur as a result of difficult dissection during laparoscopic cholecystectomy can be visualized reliably using this technique.

Introduction: Idiopathic segmental infarction of the peritonealized intra-abdominal fatty tissue is a rare cause of acute abdominal distress. Patients are operated for by suspected acute appendicitis or cholecystitis, and the true diagnosis is made intraoperatively., Methods: A 32-year-old woman was admitted to our hospital with a 2-day history of pain in the right upper abdomen. Clinical presentation suggested acute cholecystitis, but laboratory evaluation and sonography revealed no pathological findings. Because of a distinctly palpable and very painful epigastric tumor 2 x 3 x 3 cm, a CT scan was performed, that showed a clearly circumscribed mass in the ligamentum teres hepatis with hyperattenuating, infiltrating streaks. Laparoscopy was performed, and a tumor was found, that was adherent to the stomach's antrum and could easily be resected. Twenty-four hours after surgery the patient only felt slight discomfort and could be dismissed on the second day. Pathology report revealed a hemorrhagic infarction of the fatty tissue, which can be histologically found in idiopathic segmental necrosis of the greater omenum or the appendices epiploicae., Conclusions: Laparoscopy is an excellent diagnostic tool and also has therapeutic possibilities. Resection of the necrotic tissue ensures faster recovery and pain control and should be performed to prevent complications such as bacterial superinfection with formation of an abscess or spontaneous bleeding.

Objective: To examine the current clinical problem of life-threatening hemorrhage during sacrospinous vaginal vault suspension, define a management solution, and validate current anatomic knowledge of the area involved., Methods: Ten cadaveric female pelves were dissected from a posterior gluteal approach and from an abdominal approach. The vascularity of the region of the sacrospinous ligament was mapped., Results: There are multiple and varied collateral vascular supplies and anastomoses in the region of the sacrospinous ligament and buttock, including: 1) superior gluteal, 2) inferior gluteal, 3) internal pudendal, 4) vertebral, 5) middle sacral, 6) lateral sacral, and 7) external iliac via the circumflex femoral artery system. Anastomoses occurred in all pelves examined. The frequency of each type of anastomosis varied from 20-100%., Conclusion: Surgical ligation of the internal iliac artery would not likely curb massive hemorrhage during sacrospinous ligament fixation, except in certain cases of internal pudendal vascular injury. The inferior gluteal artery is probably the most commonly injured vessel in sacrospinous ligament suspension because of its location. Inferior gluteal vessel injury should be approached by the use of packing and vascular clips or packing and arterial embolization. These latter approaches should be of primary consideration in the control of hemorrhage at the time of sacrospinous ligament fixation.

Anatomical findings from 28 breast specimens of female corpses have shown a thin horizontal fibrous septum, originating from the pectoral fascia along the level of the fifth rib, heading toward the nipple. This fibrous septum lies in between a cranial and a caudal vascular network, and being mesentery-like, it is responsible for the supply of the nipple areola complex. The cranial vascular sheet is supplied by the thoracoacromial artery and a branch of the lateral thoracic artery, whereas the caudal sheet is supplied by perforating branches from anastomoses of intercostal arteries. The fibrous septum is also a guiding structure for the main supplying nerve of the nipple. At its borders the septum curves upward into a vertical medial and lateral ligament, which attach the breast to the sternum and the lateral edge of pectoralis minor. These ligaments also contain a regular nerve and vascular supply. In their total, the fibrous septum and its ligaments form a sling of dense connective tissue that acts as a brassiere-like suspensory system. These two structures, the fibrous sling and the vascular and nervous membranes attached to it, are consistent anatomical findings, which have not been described before. Their knowledge could be of value and relevance in clinical application.

The craniocervical regions of seven cadavers (14 sides) injected with silicone rubber were dissected under a Zeiss OPMI surgical microscope. The present study provides a detailed description of the suboccipital segment of the vertebral artery, with particular attention to its loops, branches, supporting osteofibrous structures, adjacent nerves, and surrounding venous structures. Several ligaments fixating the vertebral artery to surrounding structures, which have not been described in previous anatomical studies, were found. The authors propose an anatomically based subdivision of the suboccipital segment of the vertebral artery into five subsegments: infraforaminal, foraminal, supraforaminal, horizontal, and intramembranous. Measurements of surgically and clinically important features were obtained. Surgical approaches to this region are suggested based on a more informed understanding of the local anatomy.

The hepatic falciform ligament artery (HFLA) was evaluated by angiography and also by dissections. Based on the findings, the mechanism of the post-chemoembolization skin rash was studied. A total of 340 liver cirrhosis patients who underwent hepatic artery chemoembolization for hepatocellular carcinoma were reviewed in terms of the angiographic incidence of the HFLA, variations in its origin, and the incidence of skin rash. The HFLA was demonstrated in 26 (7.6%) of the 340 patients on angiography. Two HFLAs were observed in one patient. The origin was the middle hepatic artery (A4) in 16 cases, the superior branch of the middle hepatic artery in three, the inferior branch of the middle hepatic artery in two, the inferior branch of the left hepatic artery (A3) in three, and the confluence of A3 and A4 in three cases. There were no patients who developed post-chemoembolization skin rash. Two cadavers were dissected to investigate the anastomosis between the HFLA and the subcutaneous artery. Two different anastomoses were found: (1) direct and (2) via the ensiform branch of the internal thoracic artery. These were located at the lower and upper part of the falciform ligament, respectively. The distribution of a chemotherapeutic agent through these anastomoses is the likely cause of post-chemoembolization skin rash. If prophylactic embolization of the proximal portion of the HFLA using a metallic coil is performed, the skin rash will be prevented.

The structure, range of functions, blood supply, nerve supply, biochemical composition and development of tendons and ligaments are reviewed. The importance of their cells is often overlooked because of the obvious role of the extracellular matrix (ECM) in determining the physical properties of tendons and ligaments. However, it is emphasised that tendon and ligament cells have elaborate cell processes that form a three dimensional network extending throughout the extracellular matrix. The cells communicate with each other via gap junctions that could form the basis of an important load sensing system allowing the tendon to modify its ECM. Tendons and ligaments have three specialised regions along their length-the myotendinous junction, the region where tendons change direction by wrapping around bony pulleys and the enthesis (bony insertion site). The myotendinous junction is a common site of muscle strains and pulls, the wrap-around region is frequently fibrocartilaginous and a common site for degenerative change, and the enthesis may be fibrous or fibrocartilaginous according to location, and is a common site for degenerative changes or 'enthesopathies'. Enthesis fibrocartilage is just one of a series of protective devices reducing wear and tear at insertion sites. Consideration is also given to the structure and function of tendon sheaths and to the dramatic effects of exercise and deprivation on tendons and ligaments-exercise strengthens, but even relatively short periods of immobilisation can dramatically weaken tendons and ligaments.

The purpose of this study was to determine whether endothelin-1 (ET-1), endothelin-2 (ET-2) or endothelin-3 (ET-3) alter the vascular diameter of capillaries in the spiral ligament. Changes in vascular tone were measured in capillaries from the isolated spiral ligament in vitro. Capillaries were occluded on one end and opened on the other end. Red blood cells trapped in the capillaries served as markers for a luminal volume defined by the red cell itself, the capillary wall and the occluder. Movement of the red cell toward the open end was taken as evidence for vasoconstriction and movement of the red cell toward the occluder was taken as evidence for vasodilation. The inner diameter of the capillaries was 7.0 microm and decreased maximally by a factor of 0.8 in response to ET-1 and ET-2 (both 10(-8) M). Vasoconstriction induced by ET-1 and ET-2 was concentration-dependent in the range between 10(-12) and 10(-8) M whereas ET-3 (10(-8) M) had no effect. The EC50s for ET-1 and ET-2 were 1.2 x 10(-10) M and 1.4 x 10(-9) M, respectively. Thus, the potency order was ET-1 > ET-2 >> ET-3. Vasoconstriction induced by ET-1 and ET-2 was completely inhibited by the competitive antagonist 10(-6) M BQ-123 (cyclic D-Asp-L-Pro-D-Val-L-Leu-D-Trp). Vasoconstriction induced by ET-1 or ET-2 continued for more than 1 min after removal of agonist from the perfusate. Rapid vasodilation of capillaries preconstricted by ET-1 was observed in response to 10(-3) M sodium nitroprusside. Sodium nitroprusside, however, had no significant effect on the vascular diameter of resting capillaries. These results demonstrate that capillaries in the spiral ligament can constrict and the endothelin-mediated vasoconstriction occurs via ET(A) receptors.