ENDOSCOPIC SURGERY OF THE POTENTIA L ANATOMICAL SPACE S Endoscopic Surgery of the Potential Anatomical Spaces E dited by ATTILIO MARIA FARINON , MD , FACS P rofessor of Surgery and Chairman, Department of Surgery, Universit y o f Rome “Tor Ver g ata”, R ome, Italy D epartment of Surgery, University of Rome Tor Vergata , R ome, Italy Assistant E dito r : FRAN C E SCO R U LLI A C.I.P. Catalogue record for this book is available from the Library of Congress. ISBN 1-4020-2809-1 ( HB ) Published b y Sprin g er, P.O. Box 17 , 3300 AA Dordrecht , The Netherlands. Sold and distributed in North , Central and South America b y Sprin g er, I n all other countries , sold and distributed by Springer, P.O. Box 322, 3300 AH Dordrecht, The Netherlands. P rinted on acid- f ree paper A ll Rights Reserved N o part of this work may be reproduced, stored in a retrieval system, or transmitted i n any form or by any means, electronic, mechanical, photocopying, microfilming, recording o r otherwise, without written permission from the Publisher, with the exception o f any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Print ed in th e N e th e rlan ds. I SBN 1-4020-2846-6 ( e-book ) 101 Phili p Drive, Norwell, MA 0 2061 , U.S.A . © 2 0 0 5 Springe r “ And it ought to be remebered that there i s n ot hi ng more di ff i cu l ttota k e i n h an d , more p erilous to conduct, or more uncertain in its s uccess, t h an to ta k et h e l ea di nt h e i ntro d uc - t ion of a new order of thin g s. Because the i n - n ovator h as for enem i es a ll t h ose w h o h ave d one we ll un d er t h eo ld con di t i ons , an d lukewarm defenders in those who ma y do well u n de rt he n ew. ” N . Machiavelli: Th e Pr ince ( Cha p ter VI ) , 1531 Contents L i st of Contr i butors ix F orewor d xi C hapter 1 1 A ntomical Space s R ic h ar d L. M. N ewe ll C hapter 2 9 R adiolo gy of the anatomical compartment s E ttore S q ui ll aci, Rita Cammarata, Giovanni Simonett i C hapter 3 35 S urgical endoscopic access to potential anatomical spaces : a m u l t idi sc i p li nary i ssue A ttilio M a r ia F a r inon C ha p ter 4 39 T ec h n i ca l aspects for access i nto t h e nec k( m i n i ma lly i nvas i v e v ideo-assisted th y roidectom y -MIVAT ) P ao l o Micco l i, Ga b rie l e Materazzi C hapter 5 47 V ideo-assisted thoracosco p ic access to the mediastinu m T ommaso C l au d io Mineo, Eugenio Pompe o C hapter 6 6 7 M inimally invasive access to the axill a Gian f ranco Tucci, C l au d io Amanti C hapter 7 8 3 V ideo-assisted a pp roach to the retro p eritoneu m F rancesco Mica l i , F l avio Fort e C hapter 8 99 E xtra p er i tonea l v id eo-ass i ste d a pp roac h to t h ea bd om i na l aort a J o h n J . C astronuov o C hapter 9 109 T otal extraperitoneal approach (TEP) for inguinal hernia repai r F rancesco Mosca, An d rea Pietra b issa, Car l o Morett o C hapter 1 0 11 9 Video-assisted access to the subfascial space of the le g F rancesco Ru ll i , Ga b rie l eGa l atà , Mic h e l e Gran de C hapter 11 1 3 1 New Tec h no l og i es i nm i n i ma ll y i nvas i ve surger y An g e l o Benevento, Lui g i Bon i A uthor i nde x 147 S ubject index 149 v iii List of contributors C . Amanti Assistant Pro f essor o f Sur g er y , Department o f Sur g er y , Universit y o f Rom e “ La Sapienza”, Rome, Ita ly A .B e n eve nt o P ro f essor o f Sur g er y , Universit y o f Insubria, Varese, Ital y L. B o n i Assistant Pro f essor o f Surgery, Department o f Surgery, University o f Insu b ria, V arese, Ita ly R. C ammarat a R esident, Institute of Radiology, University of Rome “Tor Vergata”, Rome, It - a ly J . J . C astronuovo C linical Pro f essor o f Sur g er y , Universit y o f Medicine and Dentistr y ,Ne w Jersey Me d ica l Sc h oo l , Newar k ,C h airman, Division o f Vascu l ar Surgery , M orristown Memoria l Hospita l , Morristown, New Jerse y , USA A .M.Far i n on P rofessor of Surgery, Department of Surgery, University of Rome “To r V ergata”, Rome, Ita ly F . Fo rt e C linical Researcher in Urolo gy , Department o f Sur g er y , Universit y o f Rom e “ Tor Vergata”, Rome, Ita ly G . G alat à R esi d ent in Genera l Sur g er y , Department o f Sur g er y , Universit y o f Rome “To r V ergata”, Rome, Ital y M. G rand e Assistant Pro f essor o f Sur g er y , Department o f Sur g er y , Universit y o f Rom e “ Tor Ver g ata”, Rome, Ital y G . Materazz i Cl inica l Researc h er in Surgery, University o f Pisa, Pisa, Ita l y F. M ic al i P rofessor of Urology, Department of Surgery, University of Rome “To r V ergata”, Rome, Ita ly P .Mi cco l i P ro f essor o f Sur g er y , Universit y o f Pisa, Pisa, Ital y T. C. M i neo P ro f essor o f T h oracic Surgery, Department o f Surgery, University o f Rom e “ Tor Ver g ata”, Rome, Ital y C . Moretto C linical Researcher in Surgery, University of Pisa, Pisa, Italy F . M osc a P ro f essor o f Sur g er y , Universit y o f Pisa, Pisa, Ita ly R. N ewel l C linical Anatomist, Cardi ff School o f Biosciences, Cardi ff Universit y , Cardi ff , Wa l es; Honorary Consu l tant Ort h opae d ic Surgeon, Roya l Devon an d Exete r Healthcare NHS , Trust Exeter , UK A .P ie tra biss a Associate Pro f essor o f Surgery, University o f Pisa, Pisa, Ita ly E . P om p eo Assistant Pro f essor o f T h oracic Sur g er y , Department o f Sur g er y , Universit y o f R ome “Tor Vergata”, Rome, Italy F. Rull i Associate Pro f essor o f Surgery, Department o f Surgery, University o f Rom e “ Tor Ver g ata”, Rome, Ital y G .S i monett i P ro f essor o f Ra d io l ogy, Institute o f Ra d io l ogy, University o f Rome “To r V er g ata”, Rome, Ita ly E. Squ i llac i Associate Professor of Radiology, Institute of Radiology, University of Rom e “ Tor Vergata”, Rome, Ita ly G. Tucc i Associate Pro f essor o f Sur g er y , Department o f Sur g er y , Universit y o f Rom e “ Tor Vergata”, Rome, Ita ly x Foreword “ Anatomical potential spaces” is an attractive and no more abstract concep t that offers new perspectives to a surgical world that is rapidily changing an d b ecom i n g more comp l ex . P owerful new technolo g ies demand our attention and testif y that our clinica l wor k an d researc h are d eep l y i nf l uence db y surg i ca li nnovat i ons. T h ese l atte r dramaticall y modified approaches to treatment throu g h the introduction of e n - tirely new interventions such as minimally invasive surgical procedures, whos e rea l appea li s represente dbyl ess i nvas i veness . T his constantl y evolvin g research environment has g ained lar g e acceptance b y s urgeons accustome d to prompt a d aptat i on to a new tren d an di nc li ne d to n im - ble behaviour in the face of innovations. This behaviour, however, requires a rigorous control in order to lead to more reliable, evidence-based practice an d to s l ow or h a l tt h e ent h us i asm for some h armfu l or un h e l pfu l treatments, espe - c iall y if the y are proven to be no better than standard procedures. Thi s p art i cu l ar area of concern h as rece i ve d our attent i on: to un d erstan d whether innovations should be considered as evolutionar y variations on a s tandard procedure or the first stage of what should become recognized as a f ormal sur g ical research pro j ect . A TTILIO MARIA FARINON A A P rofessor of Genera l Surger y Un i vers i t y of Rome “Tor Ver g ata ” CHAPTER 1 ANATOMICAL SPACES R ichard L. M. Newell BSc MB BS FRC S C l inica l Anatomist, Car d i ff Sc h oo l o f Biosciences, Car d i ff University, Car d i ff ,Wa l es, UK Honorary Consu l tant Ort h opae d ic Surgeon, Roya l Devon an d Exeter Hea l t h care NHS Trust, Exeter , UK F or t h ey inquire o f t h e parts… b ut t h ey inquire not o f the secrecies o f the passa g e s . F rancis Bacon, T h eA d vancement o f Learning, 1605 F ranc i s Bacon foun d man yd ef i c i enc i es i nme di ca l sc i ence an di n part i cu l a r in ‘the inquir y which is made b y anatom y ’. Four hundred y ears later, there ar e a reas st ill i na d equate l y recogn i se db y stan d ar d topograp hi ca l an d surg i ca l anat - o m y , thou g h most of these areas have in the past attracted transient and subs e - quently forgotten interest. One such area is a true passage of secrecy: the ana t - o m y of t h e potent i a l anatom i ca l spaces . THE SEMANTICS OF SPACES Desp i te t h e convent i ons of common usage, space i sno l onger s i mp l ya t h ree- di mens i ona l , topo g rap hi ca l concept. For Kant ( Kemp Sm i t h , 1933 ) spac e was not a conce p t at all, but a p ur e a p rior i i ntuition, something which had to b e a ccepte d for t h e rest of hi s system to wor k .T h ea ddi t i on of t h e i n d ef i n i te art i c le – f rom ‘space’ to ‘a space’- ma y chan g e the concept completel y . One wonder s h ow suc h ac h ange may b e expresse di n l anguages w hi c hl ac k suc h an art i c l e : c ontext must suff i ce. To d a y ,t h e mean i n g of ‘space’ d epen d s upon t h e rea l m in which it is used. Architectural s p ace is functional: its control, delimitation an d env i sage d usage d eterm i nes t h es h ape of structures b u il ttoenc l ose or revea lit (L y m, 1980). Postmodern space encompasses the g eo g raphical (Diprose an d 1 A .M. Farinon ( e d . ) ,En d oscopic Sur g er y o f t h e Potentia l Anatomica l Spaces , 1 – 8 . © 2005 S prin g er. Printed in the Netherlands. [...]... surfaces of the gall-bladder and the under surface and posterior border of the left lobe; it is then reflected from the upper surface of the left lobe to the diaphragm as the inferior layer of the left triangular ligament and from the porta of the liver and the fossa for the ductus venosus to the lesser cuvature of the stomach and the first 2.5 cm of the duodenum as the anterior layer of the hepatogastric... reflected upon the sides of the bodies of the vertebræ From the vertebral column the pleura passes to the side of the pericardium; it then covers the back part of the root of the lung, from the lower border of which a triangular sheet descends vertically toward the diaphragm This sheet is the posterior layer of a wide fold, known as the pulmonary ligament From the back of the lung root, the pleura may... reaches from the umbilicus to the under surface of the liver This reflection forms a somewhat triangular fold, the falciform ligament of the liver, attaching the upper and anterior surfaces of the liver to the diaphragm and abdominal wall With the exception of the line of attachment of this ligament, E SQUILLACI ET AL 27 the peritoneum covers the whole of the under surface of the anterior part of the diaphragm... each other and ultimately fuse, to form a small, triangular fold connecting the right lobe of the liver to the diaphragm and named the right triangular ligament of the liver The apex of the triangular bare area corresponds with the point of meeting of the two layers of the coronary ligament, its base with the fossa for the inferior vena cava (b) It covers the lower surface of the quadrate lobe, the under... from it to the upper surface of the right lobe of the liver as the superior layer of the coronary ligament and on to the upper surface of the left lobe as the superior layer of the left triangular ligament of the liver Covering the upper and anterior surfaces of the liver, it is continued around its sharp margin on to the under surface, where it presents the following relations: (a) It covers the under... medialward in front of the inferior vena cava, where it is continuous with the posterior wall of the omental bursa Between the two layers of the coronary ligament there is a large triangular surface of the liver devoid of peritoneal covering; this is named the bare area of the liver, and is attached to the diaphragm by areolar tissue Toward the right margin of the liver the two layers of the coronary ligament... lines the parietes is named the parietal portion of the peritoneum; that which is reflected over the contained viscera constitutes the visceral portion of the peritoneum The free surface of the membrane is smooth, covered by a layer of flattened mesothelium and lubricated by a small quantity of serous fluid Hence the viscera can glide freely against the wall of the cavity or against one another with the. .. covers the surface of the lung and dips into the fissures between its lobes The parietal pleura is the rest of the membrane and lines the inner surface of the chest wall, covers the diaphragm and is reflected over the structures occupying the middle of the thorax Figure 15 Volume Rendering coronal CT image of the thorax Visceral pleura is well evident (arrows) The two layers are continuous with one another... traced over the costal surface of the E SQUILLACI ET AL 23 Figure 16 CT axial plane The two pleural layers are visible in a case of effusion (arrows) lung, the apex and base and also over the sides of the fissures between the lobes, on to its mediastinal surface and the front part of its root [4] THE ABDOMEN The abdomen is the largest cavity of the body It has an oval shape, the extremities of the oval... under surface of the right lobe and is reflected from the back part of this on to the right suprarenal gland and upper extremity of the right kidney, forming in this situation the inferior layer of the coronary ligament; a special fold, the hepatorenal ligament, is frequently present between the inferior surface of the liver and the front of the kidney From the kidney it is carried downward to the duodenum . ENDOSCOPIC SURGERY OF THE POTENTIA L ANATOMICAL SPACE S Endoscopic Surgery of the Potential Anatomical Spaces E dited by ATTILIO MARIA FARINON , MD , FACS P rofessor of Surgery and. stud y of the sectional anatom y of the human bod yg oes back to the ear - li est d ays of systemat i c topograp hi ca l anatomy. T h e b eaut i fu ld raw i ngs of t he s a gi tta l sect i ons of. ankle), in the study of the ear and the facial bones. 1 0 Endoscopic sur g er y of the potential anatomica l E. SQUILLACI ET AL. 11 A BC F igure 1 Vo l ume Ren d er i ng CT i mage of norma l a bd om i na l aorta ( A ) . Abdominal