Petros Mirilas - Academia.edu (original) (raw)

Papers by Petros Mirilas

Research paper thumbnail of <i>Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part I. Normal Developmental Anatomy (Embryogenesis) for the Surgeon</i>

American Surgeon, Sep 1, 2011

Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the... more Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the “architecture” of the neck. The embryonic pharynx (which includes future oral and nasal cavities) is a much more extensive area than the adult pharynx. The main feature of the developing pharynx is a series of arches, internal pouches, and external clefts, which together comprise the pharyngeal apparatus. This structure is associated with other developing splanchna of the neck, e.g., the thyroid and parathyroid glands, tonsils, and thymus. Within each of the pharyngeal arches are the developing aortic arches and, specific for each arch, cranial nerves. The complex relations of the mesenchymal derivatives of arches (muscles, cartilage, bones) with the neurovascular bundles within each arch are presented and explained. The pharyngeal apparatus undergoes dramatic transformations: pouches and clefts disappear without interruption (interruption would produce gills and support the misnomer “branchial apparatus”). In addition, in the lateroventral neck, somites migrate to produce other muscles such as sternocleidomastoid and trapezius innervated by spinal nerves. Lateral congenital anomalies largely rely on persistence of a cleft/and or pouch or communication between the two. Their tracts have a “crooked” course among other entities generated by alterations that take place during embryogenesis.

Research paper thumbnail of Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part III. Cadaveric Representation of the Course of Second and Third Cleft and Pouch Fistulas

American Surgeon, Sep 1, 2011

Research paper thumbnail of Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part II. Anatomy of the Abnormal for the Surgeon

American Surgeon, Sep 1, 2011

Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the... more Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the ''architecture'' of the neck. The embryonic pharynx (which includes future oral and nasal cavities) is a much more extensive area than the adult pharynx. The main feature of the developing pharynx is a series of arches, internal pouches, and external clefts, which together comprise the pharyngeal apparatus. This structure is associated with other developing splanchna of the neck, e.g., the thyroid and parathyroid glands, tonsils, and thymus. Within each of the pharyngeal arches are the developing aortic arches and, specific for each arch, cranial nerves. The complex relations of the mesenchymal derivatives of arches (muscles, cartilage, bones) with the neurovascular bundles within each arch are presented and explained. The pharyngeal apparatus undergoes dramatic transformations: pouches and clefts disappear without interruption (interruption would produce gills and support the misnomer ''branchial apparatus''). In addition, in the lateroventral neck, somites migrate to produce other muscles such as sternocleidomastoid and trapezius innervated by spinal nerves. Lateral congenital anomalies largely rely on persistence of a cleft/and or pouch or communication between the two. Their tracts have a ''crooked'' course among other entities generated by alterations that take place during embryogenesis. ''If there are obstacles, the shortest line between two points may be the crooked line.''-Galileo by Bertolt Brecht This series of articles is in memory of Dr. John E. Skandalakis (1920-2009), my valued mentor. It was the last project he advised me on. It was an honor to have been supported and encouraged by such a great anatomist, embryologist, surgeon, and humanitarian.

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces Part II: The Architecture of the Retroperitoneal Space

American Surgeon, 2010

z Editors Note: At the time of his death on August 29, 2009, at age 89, Dr. John Skandalakis was ... more z Editors Note: At the time of his death on August 29, 2009, at age 89, Dr. John Skandalakis was still passionate that surgeons must understand anatomy and basic embryology to avoid mistakes and complications. A surgeon, anatomist, author, and master teacher, his profound wisdom and kindness inspired generations of students.

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces, Part IV: Retroperitoneal Nerves

American Surgeon, Mar 1, 2010

Multi-walled carbon nanotubes were used successfully for the removal of Copper(II), Lead(II), Cad... more Multi-walled carbon nanotubes were used successfully for the removal of Copper(II), Lead(II), Cadmium(II), and Zinc(II) from aqueous solution. The results showed that the % adsorption increased by raising the solution temperature due to the endothermic nature of the adsorption process. The kinetics of Cadmium(II), Lead(II), Copper(II), and Zinc(II) adsorption on Multi-walled carbon nanotubes were analyzed using the fraction power function model, Lagergren pseudo-first-order, pseudo-second-order, and Elovich models, and the results showed that the adsorption of heavy metal ions was a pseudo-second-order process, and the adsorption capacity increased with increasing solution temperature. The binding of the metal ions by the carbon nanotubes was evaluated from the adsorption capacities and was found to follow the following order: Copper(II) [ Lead(II) [ Zinc(II) [ Cadmium(II). The thermodynamics parameters were calculated, and the results showed that the values of the free energies were negative for all metals ions, which indicated the spontaneity of the adsorption process, and this spontaneity increased by raising the solution temperature. The change in entropy values were positives, indicating the increase in randomness due to the physical adsorption of heavy metal ions from the aqueous solution to the carbon nanotubes' surface. Although the enthalpy values were positive for all metal ions, the free energies were negative, and the adsorption was spontaneous, which indicates that the heavy metal adsorption of Multiwalled carbon nanotubes was an entropy-driving process.

Research paper thumbnail of Editorial Comment to Surgical comparison of subinguinal and high inguinal microsurgical varicocelectomy for adolescent varicocele

International Journal of Urology, Feb 26, 2016

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces, Part V: Surgical Applications and Complications

American Surgeon, Apr 1, 2010

We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal ... more We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal space: 1) six named parietal nerves, branches of the lumbar plexus: iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, femoral. 2) The sacral plexus is formed by the lumbosacral trunk, ventral rami of S1-S3, and part of S4; the remainder of S4 joining the coccygeal plexus. From this plexus originate the superior gluteal nerve, which passes backward through the greater sciatic foramen above the piriformis muscle; the inferior gluteal nerve also courses through the greater sciatic foramen, but below the piriformis; 3) sympathetic trunks: right and left lumbar sympathetic trunks, which comprise four interconnected ganglia, and the pelvic chains; 4) greater, lesser, and least thoracic splanchnic nerves (sympathetic), which pass the diaphragm and join celiac ganglia; 5) four lumbar splanchnic nerves (sympathetic), which arise from lumbar sympathetic ganglia; 6) pelvic splanchnic nerves (nervi erigentes), providing parasympathetic innervation to the descending colon and pelvic splanchna; and 7) autonomic (prevertebral) plexuses, formed by the vagus nerves, splanchnic nerves, and ganglia (celiac, superior mesenteric, aorticorenal). They include sympathetic, parasympathetic, and sensory (mainly pain) fibers. The autonomic plexuses comprise named parts: aortic, superior mesenteric, inferior mesenteric, superior hypogastric, and inferior hypogastric (hypogastric nerves). ''Many a clinical reputation lies buried behind the peritoneum. In this hinterland of straggling mesenchyme, with its vascular and nervous plexuses, its weird embryonic rests, its shadowy fascial boundaries, the clinician is often left with only his flair and his diagnostic first principles to guide him.'' Editorial, The Lancet, 1957

Research paper thumbnail of <i>Obturator Hernia Revisited: Surgical Anatomy, Embryology, Diagnosis, and Technique of Repair</i>

American Surgeon, Sep 1, 2011

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues throug... more Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces, Part III: Retroperitoneal Blood Vessels and Lymphatics

American Surgeon, Feb 1, 2010

We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal ... more We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal space: 1) six named parietal nerves, branches of the lumbar plexus: iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, femoral. 2) The sacral plexus is formed by the lumbosacral trunk, ventral rami of S1-S3, and part of S4; the remainder of S4 joining the coccygeal plexus. From this plexus originate the superior gluteal nerve, which passes backward through the greater sciatic foramen above the piriformis muscle; the inferior gluteal nerve also courses through the greater sciatic foramen, but below the piriformis; 3) sympathetic trunks: right and left lumbar sympathetic trunks, which comprise four interconnected ganglia, and the pelvic chains; 4) greater, lesser, and least thoracic splanchnic nerves (sympathetic), which pass the diaphragm and join celiac ganglia; 5) four lumbar splanchnic nerves (sympathetic), which arise from lumbar sympathetic ganglia; 6) pelvic splanchnic nerves (nervi erigentes), providing parasympathetic innervation to the descending colon and pelvic splanchna; and 7) autonomic (prevertebral) plexuses, formed by the vagus nerves, splanchnic nerves, and ganglia (celiac, superior mesenteric, aorticorenal). They include sympathetic, parasympathetic, and sensory (mainly pain) fibers. The autonomic plexuses comprise named parts: aortic, superior mesenteric, inferior mesenteric, superior hypogastric, and inferior hypogastric (hypogastric nerves). ''Many a clinical reputation lies buried behind the peritoneum. In this hinterland of straggling mesenchyme, with its vascular and nervous plexuses, its weird embryonic rests, its shadowy fascial boundaries, the clinician is often left with only his flair and his diagnostic first principles to guide him.'' Editorial, The Lancet, 1957

Research paper thumbnail of Stress response to ovariohysterectomy in rabbits: role of anaesthesia and surgery

Journal of Obstetrics and Gynaecology, Mar 8, 2018

The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopi... more The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopic total ovariohysterectomy (TOH) in rabbits, by comparing surgical stress markers of laparoscopic group with those of conventional open ovariohysterectomy and open ovariohysterectomy with pre-incisional local anaesthesia groups. Blood was sampled from 18 rabbits, of which six underwent laparoscopic TOH, six conventional open TOH and six conventional open TOH with pre-incisional local anaesthesia, 30 min before induction of anaesthesia (T0), immediately after skin incision (T1), 90 min postoperatively (T2), and 24 h postoperatively (T3). Cortisol and C-reactive protein serum, and adrenocorticothrophic hormone, tumour necrosis factor-a (TNF-a), adrenaline, noradrenaline and IL-6 plasma concentrations were evaluated. Laparoscopic TOH in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations immediately after skin incision (p ¼ .04), as well as plasma adrenaline (p ¼ .035) and TNF-a (p ¼ .047) concentrations 24 h postoperatively.

Research paper thumbnail of Embryogenesis of Ectopic Bronchogenic Cysts: Keep It Simple

Journal of Investigative Surgery, 2018

Research paper thumbnail of Reply to the Letter to the Editor Regarding “Laparoscopic Hyperthermic Intraperitoneal Chemotherapy is Safe for Patients with Peritoneal Metastases from Gastric Cancer and May Lead to Gastrectomy”

Annals of Surgical Oncology, 2019

Research paper thumbnail of Sonographic Detection of Lymph Nodes in the Intussusception of Infants and Young Children

American Journal of Roentgenology, 2002

Research paper thumbnail of Right or left thoracotomy for esophageal atresia and right aortic arch? Systematic review and surgicoanatomic justification

Journal of Pediatric Surgery, Nov 1, 2018

Introduction: The optimal thoracotomy approach for the management of esophageal atresia and trach... more Introduction: The optimal thoracotomy approach for the management of esophageal atresia and tracheoesophageal fistula (EA/TEF) with a right aortic arch (RAA) remains controversial. Methods: Systematic review of complications and death rates between right-and leftsided repairs, including all studies on EA/TEF and RAA, apart from studies focusing on long-gap EA and thoracoscopic repairs. Review of right-and left-sided surgical anatomy in relation to reported complications. Results: Although no significant differences were elicited between right-and leftsided repairs in complications (9/29 vs. 1/6, p=0.64) and death rates (2/29 vs. 0/6, p=0.57), unique anatomic complications-such as injury to the RAA covering the esophagus and intractable bleeding-associated with mortality were revealed in the right thoracotomy group. Left-sided repairs following failed repair through the right showed higher complications rate (3/3) than straightforward right-(9/29) or left-sided repairs (1/6) (p=0.024). Right thoracotomies converted to left thoracotomies led to staged repairs more frequently (4/9) than straightforward right (5/38) or left thoracotomies (0/6) (p=0.03). Conclusions: There is not enough evidence to support that right thoracotomy, characterized by unique surgicoanatomic difficulties, is equivalent to left thoracotomy for EA/TEF with RAA. Both approaches might be required, and, therefore, surgeons should be familiarized with surgical anatomy of mediastinum approached from right and left.

Research paper thumbnail of Surgical disorders in pediatric and adolescent gynecology: Vaginal and uterine anomalies

International journal of gynaecology and obstetrics, Aug 12, 2022

Obstructive vaginal and uterine anomalies including imperforate hymen, transverse vaginal septum,... more Obstructive vaginal and uterine anomalies including imperforate hymen, transverse vaginal septum, and vaginal and/or cervical atresia or aplasia, might rarely present in infancy or childhood with hydrocolpos and/or hydrometra but they usually go unrecognized until presentation with amenorrhea and hematocolpos and/or hematometra in puberty. They should always be included in the differential diagnosis of a suprapubic and/or introital mass; in the latter case, vaginal vascular malformations and vaginal tumors should also be considered. Uterovaginal aplasia typically manifests with amenorrhea in puberty and needs to be differentiated from complete androgen insensitivity syndrome and gonadal dysgenesis of genetic males. Uterine fusion anomalies usually present with fertility and/or obstetrical complications in adulthood. However, a unicornuate uterus with a blind rudimentary contralateral horn containing functioning endometrium, and didelphys or septate uterus with a deviating obstructive septum might present in childhood or puberty with sequelae related with secretions or menstrual retention. This review provides a collective account of the most clinically important information about vaginal and uterine anomalies in childhood and adolescence for clinicians involved in the care of young females with the aim to provide guidance in appropriate evaluation and management.

Research paper thumbnail of Sonographic Measurement of the Abdominal Esophagus Length in Infancy: A Diagnostic Tool for Gastroesophageal Reflux

American Journal of Roentgenology, 2004

OBJECTIVE. Our aim was to provide exact sonographic measurements of the abdominal esophagus lengt... more OBJECTIVE. Our aim was to provide exact sonographic measurements of the abdominal esophagus length in neonates and infants with and without gastroesophageal reflux (GER) and to investigate its diagnostic value. GER severity and hiatal hernia presence were also evaluated and correlated with esophageal length. MATERIALS AND METHODS. This retrospective case-control study comprised 258 neonates and infants (150 without reflux and 108 with reflux). There were 50 children without reflux in each of three age categories: less than 1 month, 1-6 months, and 6-12 months. Of the children with reflux, 42 were less than 1 month old; 34, 1-6 months; and 32, 6-12 months. The abdominal esophagus was measured from its entrance into the diaphragm to the base of gastric folds in fed infants. The number of refluxes during a 10-min period were recorded; GER was categorized as mild, one to three refluxes; moderate, three to six refluxes; and severe, more than six refluxes. Presence of hiatal hernia was recorded. RESULTS. Neonates and infants with reflux had a significantly shorter abdominal esophagus than subjects without reflux: the mean difference in neonates, 4.8 mm; 1-6 months, 4.5 mm; 6-12 months, 3.4 mm. Children with severe reflux had a shorter esophagus compared with those with mild and moderate reflux only in the neonate group. In contrast, children with reflux associated with hiatal hernia had a significantly shorter esophagus compared with children with mild reflux in all three age groups. Sonographic sensitivity was 94%. CONCLUSION. Sonographic measurement of the abdominal esophagus length is highly diagnostic for GER in neonates and infants. In neonates, it can also indicate GER severity. Hiatal hernia is associated with a significantly shorter abdominal esophagus.

Research paper thumbnail of Outcomes of Pediatric Endoscopic Pilonidal Sinus Treatment: A Systematic Review

European Journal of Pediatric Surgery

Treatment of pilonidal sinus disease with conventional excision techniques is associated with rec... more Treatment of pilonidal sinus disease with conventional excision techniques is associated with recurrence up to 20 to 30% (primary closure) or with prolonged healing that might last months (closure by secondary intention). Endoscopic pilonidal sinus treatment (EPSiT) is gaining increasing popularity. This systematic review aims to summarize and evaluate the reported outcomes of pediatric EPSiT (PEPSiT) to date. Systematic search was performed for all studies on PEPSiT in patients younger than 18 years, pertaining to demographics, technique, and outcomes. Fisher's test was used to assess the associations between success/recurrence rates and different approaches (fistuloscope vs. cystoscope, different wound care protocols). A total of 320 patients (9 studies, 2018–2022) with a weighted mean age of 15.7 years and follow-up duration of 13.5 months were included. PEPSiT was successful in 290 patients (90.9%) with weighted mean time to healing of 4.1 weeks. Recurrence was reported in 2...

Research paper thumbnail of Surgical disorders in pediatric and adolescent gynecology: Adnexal abnormalities

International Journal of Gynecology & Obstetrics

Research paper thumbnail of Laparoscopic Colon Surgery: Education and Best Practices

Laparoscopic Colon Surgery, 2020

The advent of laparoscopic surgery has radically changed surgical management of many diseases. So... more The advent of laparoscopic surgery has radically changed surgical management of many diseases. Soon after the first laparoscopic procedures, the development of more complex laparoscopic operations began, including laparoscopic colon surgery. However, the adoption of laparoscopic colon surgery created new educational challenges. Add to this the medical demands for increased patient safety, fewer complications from surgery, and less time in the hospital. These are strong forces towards the development of training tools and modalities that teach the types of skills needed in laparoscopic surgery. New and older educational modalities such as box and video trainers, high-fidelity laparoscopic simulators, and cadaveric and animal models are useful because they shorten the training period and minimize costs. Their appropriate use allows acquisition of basic and advanced laparoscopic surgical skills outside the operating theatre. Training time within the operating theater can be reserved for training integration and practicing on real tissue. Increasing knowledge of the advantages and limitations of different educational and training modalities is necessary so best practices can be implemented. As laparoscopic colon surgery is relatively new, it is also important to acknowledge the population of trainees is not homogenous, ranging from novice to experienced surgeons. The diverse group that comprise the surgical community, plus limitation in financial resources, make flexible and economical educational programs a necessity.

Research paper thumbnail of Laparoscopic Colon Surgery: Education and Best Practices

Laparoscopic Colon Surgery, 2020

The advent of laparoscopic surgery has radically changed surgical management of many diseases. So... more The advent of laparoscopic surgery has radically changed surgical management of many diseases. Soon after the first laparoscopic procedures, the development of more complex laparoscopic operations began, including laparoscopic colon surgery. However, the adoption of laparoscopic colon surgery created new educational challenges. Add to this the medical demands for increased patient safety, fewer complications from surgery, and less time in the hospital. These are strong forces towards the development of training tools and modalities that teach the types of skills needed in laparoscopic surgery. New and older educational modalities such as box and video trainers, high-fidelity laparoscopic simulators, and cadaveric and animal models are useful because they shorten the training period and minimize costs. Their appropriate use allows acquisition of basic and advanced laparoscopic surgical skills outside the operating theatre. Training time within the operating theater can be reserved for training integration and practicing on real tissue. Increasing knowledge of the advantages and limitations of different educational and training modalities is necessary so best practices can be implemented. As laparoscopic colon surgery is relatively new, it is also important to acknowledge the population of trainees is not homogenous, ranging from novice to experienced surgeons. The diverse group that comprise the surgical community, plus limitation in financial resources, make flexible and economical educational programs a necessity.

Research paper thumbnail of <i>Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part I. Normal Developmental Anatomy (Embryogenesis) for the Surgeon</i>

American Surgeon, Sep 1, 2011

Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the... more Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the “architecture” of the neck. The embryonic pharynx (which includes future oral and nasal cavities) is a much more extensive area than the adult pharynx. The main feature of the developing pharynx is a series of arches, internal pouches, and external clefts, which together comprise the pharyngeal apparatus. This structure is associated with other developing splanchna of the neck, e.g., the thyroid and parathyroid glands, tonsils, and thymus. Within each of the pharyngeal arches are the developing aortic arches and, specific for each arch, cranial nerves. The complex relations of the mesenchymal derivatives of arches (muscles, cartilage, bones) with the neurovascular bundles within each arch are presented and explained. The pharyngeal apparatus undergoes dramatic transformations: pouches and clefts disappear without interruption (interruption would produce gills and support the misnomer “branchial apparatus”). In addition, in the lateroventral neck, somites migrate to produce other muscles such as sternocleidomastoid and trapezius innervated by spinal nerves. Lateral congenital anomalies largely rely on persistence of a cleft/and or pouch or communication between the two. Their tracts have a “crooked” course among other entities generated by alterations that take place during embryogenesis.

Research paper thumbnail of Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part III. Cadaveric Representation of the Course of Second and Third Cleft and Pouch Fistulas

American Surgeon, Sep 1, 2011

Research paper thumbnail of Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part II. Anatomy of the Abnormal for the Surgeon

American Surgeon, Sep 1, 2011

Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the... more Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the ''architecture'' of the neck. The embryonic pharynx (which includes future oral and nasal cavities) is a much more extensive area than the adult pharynx. The main feature of the developing pharynx is a series of arches, internal pouches, and external clefts, which together comprise the pharyngeal apparatus. This structure is associated with other developing splanchna of the neck, e.g., the thyroid and parathyroid glands, tonsils, and thymus. Within each of the pharyngeal arches are the developing aortic arches and, specific for each arch, cranial nerves. The complex relations of the mesenchymal derivatives of arches (muscles, cartilage, bones) with the neurovascular bundles within each arch are presented and explained. The pharyngeal apparatus undergoes dramatic transformations: pouches and clefts disappear without interruption (interruption would produce gills and support the misnomer ''branchial apparatus''). In addition, in the lateroventral neck, somites migrate to produce other muscles such as sternocleidomastoid and trapezius innervated by spinal nerves. Lateral congenital anomalies largely rely on persistence of a cleft/and or pouch or communication between the two. Their tracts have a ''crooked'' course among other entities generated by alterations that take place during embryogenesis. ''If there are obstacles, the shortest line between two points may be the crooked line.''-Galileo by Bertolt Brecht This series of articles is in memory of Dr. John E. Skandalakis (1920-2009), my valued mentor. It was the last project he advised me on. It was an honor to have been supported and encouraged by such a great anatomist, embryologist, surgeon, and humanitarian.

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces Part II: The Architecture of the Retroperitoneal Space

American Surgeon, 2010

z Editors Note: At the time of his death on August 29, 2009, at age 89, Dr. John Skandalakis was ... more z Editors Note: At the time of his death on August 29, 2009, at age 89, Dr. John Skandalakis was still passionate that surgeons must understand anatomy and basic embryology to avoid mistakes and complications. A surgeon, anatomist, author, and master teacher, his profound wisdom and kindness inspired generations of students.

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces, Part IV: Retroperitoneal Nerves

American Surgeon, Mar 1, 2010

Multi-walled carbon nanotubes were used successfully for the removal of Copper(II), Lead(II), Cad... more Multi-walled carbon nanotubes were used successfully for the removal of Copper(II), Lead(II), Cadmium(II), and Zinc(II) from aqueous solution. The results showed that the % adsorption increased by raising the solution temperature due to the endothermic nature of the adsorption process. The kinetics of Cadmium(II), Lead(II), Copper(II), and Zinc(II) adsorption on Multi-walled carbon nanotubes were analyzed using the fraction power function model, Lagergren pseudo-first-order, pseudo-second-order, and Elovich models, and the results showed that the adsorption of heavy metal ions was a pseudo-second-order process, and the adsorption capacity increased with increasing solution temperature. The binding of the metal ions by the carbon nanotubes was evaluated from the adsorption capacities and was found to follow the following order: Copper(II) [ Lead(II) [ Zinc(II) [ Cadmium(II). The thermodynamics parameters were calculated, and the results showed that the values of the free energies were negative for all metals ions, which indicated the spontaneity of the adsorption process, and this spontaneity increased by raising the solution temperature. The change in entropy values were positives, indicating the increase in randomness due to the physical adsorption of heavy metal ions from the aqueous solution to the carbon nanotubes' surface. Although the enthalpy values were positive for all metal ions, the free energies were negative, and the adsorption was spontaneous, which indicates that the heavy metal adsorption of Multiwalled carbon nanotubes was an entropy-driving process.

Research paper thumbnail of Editorial Comment to Surgical comparison of subinguinal and high inguinal microsurgical varicocelectomy for adolescent varicocele

International Journal of Urology, Feb 26, 2016

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces, Part V: Surgical Applications and Complications

American Surgeon, Apr 1, 2010

We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal ... more We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal space: 1) six named parietal nerves, branches of the lumbar plexus: iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, femoral. 2) The sacral plexus is formed by the lumbosacral trunk, ventral rami of S1-S3, and part of S4; the remainder of S4 joining the coccygeal plexus. From this plexus originate the superior gluteal nerve, which passes backward through the greater sciatic foramen above the piriformis muscle; the inferior gluteal nerve also courses through the greater sciatic foramen, but below the piriformis; 3) sympathetic trunks: right and left lumbar sympathetic trunks, which comprise four interconnected ganglia, and the pelvic chains; 4) greater, lesser, and least thoracic splanchnic nerves (sympathetic), which pass the diaphragm and join celiac ganglia; 5) four lumbar splanchnic nerves (sympathetic), which arise from lumbar sympathetic ganglia; 6) pelvic splanchnic nerves (nervi erigentes), providing parasympathetic innervation to the descending colon and pelvic splanchna; and 7) autonomic (prevertebral) plexuses, formed by the vagus nerves, splanchnic nerves, and ganglia (celiac, superior mesenteric, aorticorenal). They include sympathetic, parasympathetic, and sensory (mainly pain) fibers. The autonomic plexuses comprise named parts: aortic, superior mesenteric, inferior mesenteric, superior hypogastric, and inferior hypogastric (hypogastric nerves). ''Many a clinical reputation lies buried behind the peritoneum. In this hinterland of straggling mesenchyme, with its vascular and nervous plexuses, its weird embryonic rests, its shadowy fascial boundaries, the clinician is often left with only his flair and his diagnostic first principles to guide him.'' Editorial, The Lancet, 1957

Research paper thumbnail of <i>Obturator Hernia Revisited: Surgical Anatomy, Embryology, Diagnosis, and Technique of Repair</i>

American Surgeon, Sep 1, 2011

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues throug... more Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.

Research paper thumbnail of Surgical Anatomy of the Retroperitoneal Spaces, Part III: Retroperitoneal Blood Vessels and Lymphatics

American Surgeon, Feb 1, 2010

We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal ... more We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal space: 1) six named parietal nerves, branches of the lumbar plexus: iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, femoral. 2) The sacral plexus is formed by the lumbosacral trunk, ventral rami of S1-S3, and part of S4; the remainder of S4 joining the coccygeal plexus. From this plexus originate the superior gluteal nerve, which passes backward through the greater sciatic foramen above the piriformis muscle; the inferior gluteal nerve also courses through the greater sciatic foramen, but below the piriformis; 3) sympathetic trunks: right and left lumbar sympathetic trunks, which comprise four interconnected ganglia, and the pelvic chains; 4) greater, lesser, and least thoracic splanchnic nerves (sympathetic), which pass the diaphragm and join celiac ganglia; 5) four lumbar splanchnic nerves (sympathetic), which arise from lumbar sympathetic ganglia; 6) pelvic splanchnic nerves (nervi erigentes), providing parasympathetic innervation to the descending colon and pelvic splanchna; and 7) autonomic (prevertebral) plexuses, formed by the vagus nerves, splanchnic nerves, and ganglia (celiac, superior mesenteric, aorticorenal). They include sympathetic, parasympathetic, and sensory (mainly pain) fibers. The autonomic plexuses comprise named parts: aortic, superior mesenteric, inferior mesenteric, superior hypogastric, and inferior hypogastric (hypogastric nerves). ''Many a clinical reputation lies buried behind the peritoneum. In this hinterland of straggling mesenchyme, with its vascular and nervous plexuses, its weird embryonic rests, its shadowy fascial boundaries, the clinician is often left with only his flair and his diagnostic first principles to guide him.'' Editorial, The Lancet, 1957

Research paper thumbnail of Stress response to ovariohysterectomy in rabbits: role of anaesthesia and surgery

Journal of Obstetrics and Gynaecology, Mar 8, 2018

The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopi... more The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopic total ovariohysterectomy (TOH) in rabbits, by comparing surgical stress markers of laparoscopic group with those of conventional open ovariohysterectomy and open ovariohysterectomy with pre-incisional local anaesthesia groups. Blood was sampled from 18 rabbits, of which six underwent laparoscopic TOH, six conventional open TOH and six conventional open TOH with pre-incisional local anaesthesia, 30 min before induction of anaesthesia (T0), immediately after skin incision (T1), 90 min postoperatively (T2), and 24 h postoperatively (T3). Cortisol and C-reactive protein serum, and adrenocorticothrophic hormone, tumour necrosis factor-a (TNF-a), adrenaline, noradrenaline and IL-6 plasma concentrations were evaluated. Laparoscopic TOH in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations immediately after skin incision (p ¼ .04), as well as plasma adrenaline (p ¼ .035) and TNF-a (p ¼ .047) concentrations 24 h postoperatively.

Research paper thumbnail of Embryogenesis of Ectopic Bronchogenic Cysts: Keep It Simple

Journal of Investigative Surgery, 2018

Research paper thumbnail of Reply to the Letter to the Editor Regarding “Laparoscopic Hyperthermic Intraperitoneal Chemotherapy is Safe for Patients with Peritoneal Metastases from Gastric Cancer and May Lead to Gastrectomy”

Annals of Surgical Oncology, 2019

Research paper thumbnail of Sonographic Detection of Lymph Nodes in the Intussusception of Infants and Young Children

American Journal of Roentgenology, 2002

Research paper thumbnail of Right or left thoracotomy for esophageal atresia and right aortic arch? Systematic review and surgicoanatomic justification

Journal of Pediatric Surgery, Nov 1, 2018

Introduction: The optimal thoracotomy approach for the management of esophageal atresia and trach... more Introduction: The optimal thoracotomy approach for the management of esophageal atresia and tracheoesophageal fistula (EA/TEF) with a right aortic arch (RAA) remains controversial. Methods: Systematic review of complications and death rates between right-and leftsided repairs, including all studies on EA/TEF and RAA, apart from studies focusing on long-gap EA and thoracoscopic repairs. Review of right-and left-sided surgical anatomy in relation to reported complications. Results: Although no significant differences were elicited between right-and leftsided repairs in complications (9/29 vs. 1/6, p=0.64) and death rates (2/29 vs. 0/6, p=0.57), unique anatomic complications-such as injury to the RAA covering the esophagus and intractable bleeding-associated with mortality were revealed in the right thoracotomy group. Left-sided repairs following failed repair through the right showed higher complications rate (3/3) than straightforward right-(9/29) or left-sided repairs (1/6) (p=0.024). Right thoracotomies converted to left thoracotomies led to staged repairs more frequently (4/9) than straightforward right (5/38) or left thoracotomies (0/6) (p=0.03). Conclusions: There is not enough evidence to support that right thoracotomy, characterized by unique surgicoanatomic difficulties, is equivalent to left thoracotomy for EA/TEF with RAA. Both approaches might be required, and, therefore, surgeons should be familiarized with surgical anatomy of mediastinum approached from right and left.

Research paper thumbnail of Surgical disorders in pediatric and adolescent gynecology: Vaginal and uterine anomalies

International journal of gynaecology and obstetrics, Aug 12, 2022

Obstructive vaginal and uterine anomalies including imperforate hymen, transverse vaginal septum,... more Obstructive vaginal and uterine anomalies including imperforate hymen, transverse vaginal septum, and vaginal and/or cervical atresia or aplasia, might rarely present in infancy or childhood with hydrocolpos and/or hydrometra but they usually go unrecognized until presentation with amenorrhea and hematocolpos and/or hematometra in puberty. They should always be included in the differential diagnosis of a suprapubic and/or introital mass; in the latter case, vaginal vascular malformations and vaginal tumors should also be considered. Uterovaginal aplasia typically manifests with amenorrhea in puberty and needs to be differentiated from complete androgen insensitivity syndrome and gonadal dysgenesis of genetic males. Uterine fusion anomalies usually present with fertility and/or obstetrical complications in adulthood. However, a unicornuate uterus with a blind rudimentary contralateral horn containing functioning endometrium, and didelphys or septate uterus with a deviating obstructive septum might present in childhood or puberty with sequelae related with secretions or menstrual retention. This review provides a collective account of the most clinically important information about vaginal and uterine anomalies in childhood and adolescence for clinicians involved in the care of young females with the aim to provide guidance in appropriate evaluation and management.

Research paper thumbnail of Sonographic Measurement of the Abdominal Esophagus Length in Infancy: A Diagnostic Tool for Gastroesophageal Reflux

American Journal of Roentgenology, 2004

OBJECTIVE. Our aim was to provide exact sonographic measurements of the abdominal esophagus lengt... more OBJECTIVE. Our aim was to provide exact sonographic measurements of the abdominal esophagus length in neonates and infants with and without gastroesophageal reflux (GER) and to investigate its diagnostic value. GER severity and hiatal hernia presence were also evaluated and correlated with esophageal length. MATERIALS AND METHODS. This retrospective case-control study comprised 258 neonates and infants (150 without reflux and 108 with reflux). There were 50 children without reflux in each of three age categories: less than 1 month, 1-6 months, and 6-12 months. Of the children with reflux, 42 were less than 1 month old; 34, 1-6 months; and 32, 6-12 months. The abdominal esophagus was measured from its entrance into the diaphragm to the base of gastric folds in fed infants. The number of refluxes during a 10-min period were recorded; GER was categorized as mild, one to three refluxes; moderate, three to six refluxes; and severe, more than six refluxes. Presence of hiatal hernia was recorded. RESULTS. Neonates and infants with reflux had a significantly shorter abdominal esophagus than subjects without reflux: the mean difference in neonates, 4.8 mm; 1-6 months, 4.5 mm; 6-12 months, 3.4 mm. Children with severe reflux had a shorter esophagus compared with those with mild and moderate reflux only in the neonate group. In contrast, children with reflux associated with hiatal hernia had a significantly shorter esophagus compared with children with mild reflux in all three age groups. Sonographic sensitivity was 94%. CONCLUSION. Sonographic measurement of the abdominal esophagus length is highly diagnostic for GER in neonates and infants. In neonates, it can also indicate GER severity. Hiatal hernia is associated with a significantly shorter abdominal esophagus.

Research paper thumbnail of Outcomes of Pediatric Endoscopic Pilonidal Sinus Treatment: A Systematic Review

European Journal of Pediatric Surgery

Treatment of pilonidal sinus disease with conventional excision techniques is associated with rec... more Treatment of pilonidal sinus disease with conventional excision techniques is associated with recurrence up to 20 to 30% (primary closure) or with prolonged healing that might last months (closure by secondary intention). Endoscopic pilonidal sinus treatment (EPSiT) is gaining increasing popularity. This systematic review aims to summarize and evaluate the reported outcomes of pediatric EPSiT (PEPSiT) to date. Systematic search was performed for all studies on PEPSiT in patients younger than 18 years, pertaining to demographics, technique, and outcomes. Fisher's test was used to assess the associations between success/recurrence rates and different approaches (fistuloscope vs. cystoscope, different wound care protocols). A total of 320 patients (9 studies, 2018–2022) with a weighted mean age of 15.7 years and follow-up duration of 13.5 months were included. PEPSiT was successful in 290 patients (90.9%) with weighted mean time to healing of 4.1 weeks. Recurrence was reported in 2...

Research paper thumbnail of Surgical disorders in pediatric and adolescent gynecology: Adnexal abnormalities

International Journal of Gynecology & Obstetrics

Research paper thumbnail of Laparoscopic Colon Surgery: Education and Best Practices

Laparoscopic Colon Surgery, 2020

The advent of laparoscopic surgery has radically changed surgical management of many diseases. So... more The advent of laparoscopic surgery has radically changed surgical management of many diseases. Soon after the first laparoscopic procedures, the development of more complex laparoscopic operations began, including laparoscopic colon surgery. However, the adoption of laparoscopic colon surgery created new educational challenges. Add to this the medical demands for increased patient safety, fewer complications from surgery, and less time in the hospital. These are strong forces towards the development of training tools and modalities that teach the types of skills needed in laparoscopic surgery. New and older educational modalities such as box and video trainers, high-fidelity laparoscopic simulators, and cadaveric and animal models are useful because they shorten the training period and minimize costs. Their appropriate use allows acquisition of basic and advanced laparoscopic surgical skills outside the operating theatre. Training time within the operating theater can be reserved for training integration and practicing on real tissue. Increasing knowledge of the advantages and limitations of different educational and training modalities is necessary so best practices can be implemented. As laparoscopic colon surgery is relatively new, it is also important to acknowledge the population of trainees is not homogenous, ranging from novice to experienced surgeons. The diverse group that comprise the surgical community, plus limitation in financial resources, make flexible and economical educational programs a necessity.

Research paper thumbnail of Laparoscopic Colon Surgery: Education and Best Practices

Laparoscopic Colon Surgery, 2020

The advent of laparoscopic surgery has radically changed surgical management of many diseases. So... more The advent of laparoscopic surgery has radically changed surgical management of many diseases. Soon after the first laparoscopic procedures, the development of more complex laparoscopic operations began, including laparoscopic colon surgery. However, the adoption of laparoscopic colon surgery created new educational challenges. Add to this the medical demands for increased patient safety, fewer complications from surgery, and less time in the hospital. These are strong forces towards the development of training tools and modalities that teach the types of skills needed in laparoscopic surgery. New and older educational modalities such as box and video trainers, high-fidelity laparoscopic simulators, and cadaveric and animal models are useful because they shorten the training period and minimize costs. Their appropriate use allows acquisition of basic and advanced laparoscopic surgical skills outside the operating theatre. Training time within the operating theater can be reserved for training integration and practicing on real tissue. Increasing knowledge of the advantages and limitations of different educational and training modalities is necessary so best practices can be implemented. As laparoscopic colon surgery is relatively new, it is also important to acknowledge the population of trainees is not homogenous, ranging from novice to experienced surgeons. The diverse group that comprise the surgical community, plus limitation in financial resources, make flexible and economical educational programs a necessity.