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Papers by Santiago Cubas

Revista Argentina de Cirugía

Santiago Cubas, 0000-0001-6026-5316; Martín Varela, 0000-0003-2376-2844; María N. Brito, 0000-000... more Santiago Cubas, 0000-0001-6026-5316; Martín Varela, 0000-0003-2376-2844; María N. Brito, 0000-0002-1394-3994; Andrés Pouy, 0000-0002-7136-144X; Nicolás D. Muniz, 0000-0002-6235-1303; Camila Haro, 0000-0003-4475-9740; Marysol Martínez, 0000-0001-8372-2006; César E. Canessa, 0000-0003-0446-7823.

SALUD MILITAR

Gastric volvulus is a rare cause for upper digestive obstruction. It is potentially lethal and re... more Gastric volvulus is a rare cause for upper digestive obstruction. It is potentially lethal and requires an urgent treatment. Its low frequency and non specific symptoms result in a late diagnosis, frequently leading to local or systemic complications. Its classic onset shows the Bortchard triad (epigastric pain, retching without vomitting and the impossibility to advance a nasogastric tube) which is observed in 70% of the patients. It is generally associated to anatomic alterations such as the hiatal hernia. A CT scan is essential to complete the etiologic diagnosis. Surgical treatment intended for gastric devolvulation and to prevent recurrences, achieves good results and can be performed through a minimally invasive procedure.

SALUD MILITAR

El leiomioma es el tumor benigno esofágico más frecuente, si bien constituye una auténtica rareza... more El leiomioma es el tumor benigno esofágico más frecuente, si bien constituye una auténtica rareza. Representa el 0,4% de todos los tumores esofágicos, muy por detrás de los tumores malignos. Es más frecuente en hombres (1,9 veces con respecto a mujeres), con un promedio de edad de 44 años, son de lento crecimiento y en ocasiones casi asintomáticos, por lo que no es raro la demora en el diagnóstico. La degeneración maligna es excepcional. Los síntomas más comunes son disfagia, dolor retroesternal, pirosis y adelgazamiento. La endoscopía y la ecoendosonografía permiten completar el diagnóstico. La cirugía está indicada en tumores sintomáticos, y el abordaje mini invasivo es la técnica de elección.

Introduction: The laparoscopic appendectomy of non-complicated acute apendicitis is a simple vide... more Introduction: The laparoscopic appendectomy of non-complicated acute apendicitis is a simple video-assisted surgery procedure. It is also possible to treat by laparoscopy those forms complicated with diffuse acute and localized peritonitis when the physician has experience in laparoscopic surgery and in the treatment of simple forms. The purpose is to show the results obtained with the laparoscopy treatment in patients with simple acute appendicitis and with peritoneal complications (diffuse and localized peritonitis). Material and methods: This Observational, retrospective, descriptive study is constituted by 148 patients treated between November, 1998 and July, 2010. Ages go from 7 to 72 years with an average of 29 years, 67 men and 81 women. 126 had non-complicated appendicitis (39 congestive, 73 phlegmonous, 13 gangrenous ones); 22 had a complicated form (14 diffuse and 8 localized peritonitis). Results: The mortality of the series was 0. Morbidity was low. A larger number of co...

RESUMEN Introduccion: La apendicectomia laparoscopica de las apendicitis agudas no complicadas es... more RESUMEN Introduccion: La apendicectomia laparoscopica de las apendicitis agudas no complicadas es un procedimiento sencillo de la cirugia videoasistida. Es tambien posible tratar por laparoscopia las formas complicadas con peritonitis difusas agudas y localizadas, cuando se tiene experiencia en cirugia laparoscopica y en el tratamiento de las formas simples. El objetivo de este trabajo es mostrar los resultados obtenidos en el tratamiento por laparoscopia de pacientes portadores de apendicitis agudas simples y con complicaciones peritoneales (peritonitis difusas y localizadas). Material y metodos: Estudio observacional, retrospectivo, descriptivo. La serie esta constituida por 148 pacientes tratados entre noviembre de 1998 y julio de 2010. Las edades oscilaron entre 7 y 72 anos con un promedio de 29 anos, 67 hombres y 81 mujeres. 126 presentaron apendicitis no complicada (39 congestivas, 73 fl emonosas, 13 gangrenosas); 22 presentaron una forma complicada (14 peritonitis difusas y 8...

Gastric cancer is the fifth most frequent malignant neoplasm worldwide and in our country, and th... more Gastric cancer is the fifth most frequent malignant neoplasm worldwide and in our country, and the fourth cause of cancer mortality. The survival rate continues to be low, since its diagnosis is usually late and in advanced stages.In countries with a high incidence, endoscopic screening is performed, making the diagnosis in early stages, with a better prognosis. In these patients there is a lower risk of regional or distant spread, and tailored treatments can be considered, avoiding wide resections.

Resección laparoscópica de schwannoma gástrico. Reporte de caso Ressecção laparoscópica do schwan... more Resección laparoscópica de schwannoma gástrico. Reporte de caso Ressecção laparoscópica do schwannoma gástrico. Relatório de caso

Acta gastroenterológica latinoamericana, 2020

Neurofibromatosis type 1, also known as von Recklinghausen disease, is an inherited neurocutaneou... more Neurofibromatosis type 1, also known as von Recklinghausen disease, is an inherited neurocutaneous disorder with gastrointestinal involvement in 5-25% of the patients, which develops following cutaneous manifestations. Only 5% have symptoms such as abdominal pain, diarrhea, palpable mass, bleeding, obstruction or intestinal perforation. There is an increased risk of developing digestive malignancies, frequently in the small bowel. The following report presents the case of a patient with neurofibromatosis type 1, with the diagnosis of a jejunal gastrointestinal stromal tumor and a fibroid inflammatory polyp in the context of gastrointestinal bleeding.

SALUD MILITAR, 2021

Una propuesta de tríada diagnóstica a propósito de un caso de oclusión por fitobezoar Uma propost... more Una propuesta de tríada diagnóstica a propósito de un caso de oclusión por fitobezoar Uma proposta para uma tríade de diagnóstico em um caso de oclusão fitobezoar

The Lancet, 2021

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little c... more Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Revista Medica del Uruguay, Sep 1, 2017

Introducción: durante muchos años se han utilizado distintos scores clínicos, paraclínicos e imag... more Introducción: durante muchos años se han utilizado distintos scores clínicos, paraclínicos e imagenológicos con el fin de predecir la morbimortalidad en la pancreatitis aguda. Dichos scores han demostrado diversa utilidad, aunque la complejidad de los mismos a la hora de su implementación ha limitado su uso en la práctica clínica habitual. Objetivo: establecer la relación del síndrome de respuesta inflamatoria sistémica (SIRS) y su duración con la mortalidad y el desarrollo de complicaciones. Material y método: se realizó un estudio multicéntrico, analítico y observacional de todos los pacientes con pancreatitis aguda (96) diagnosticados desde mayo de 2015 a mayo de 2016 en el Hospital Central de las Fuerzas Armadas (43,8%), en el Hospital de Clínicas (30,3%) y en el Hospital Español (21,9%). Resultados: el 67% de las pancreatitis agudas se desarrollaron de forma leve, 25% de forma moderada y 8% de forma severa. El 42% tenía SIRS al momento del diagnóstico y 15% mantuvieron el SIRS por más de 48 horas. El SIRS mantenido se asoció significativamente con la existencia de necrosis pancreática, falla orgánica persistente, necesidad de cuidados intensivos, presencia de complicaciones locorregionales, número aumentado de tomografías, severidad de la pancreatitis aguda y mortalidad. La mortalidad en pacientes con SIRS transitorio fue nula y con SIRS mantenido de 27%. Conclusión: el SIRS mantenido por más de 48 horas se asocia significativamente a todos los marcadores de severidad. Su ausencia o su presencia por menos de 48 horas no se asocian a mortalidad y las complicaciones locorregionales son menores.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery

Source of support: Nil Conflict of interest: None Patient consent statement: The author(s) have o... more Source of support: Nil Conflict of interest: None Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

REVISTA MEDICA DEL URUGUAY, 2019

El tratamiento de las metástasis hepáticas de origen colorrectal ha ido cambiando en estos último... more El tratamiento de las metástasis hepáticas de origen colorrectal ha ido cambiando en estos últimos 20 años. En la actualidad la cirugía constituye un pilar fundamental en el tratamiento de estos enfermos. La sobrevida de los pacientes pasibles de una resección completa del tumor puede ascender a 40% en cinco años. Estos resultados oncológicos tan alentadores han llevado a los equipos quirúrgicos a esforzarse por lograr resecciones hepáticas extremas contraindicadas en tiempos anteriores. Es, en esta línea de trabajo, que se desarrolló la cirugía de remodelación hepática que consiste en alterar el flujo portal buscando una hipertrofia del hígado sano y atrofia del enfermo. El siguiente caso pretende mostrar una de las dos cirugías de remodelación más utilizadas en el mundo, que es la hepatectomía en dos tiempos con oclusión del flujo portal. Se discute su indicación, la oportunidad de las cirugías, el beneficio oncológico y la viabilidad de su realización en nuestro medio. Palabras clave: Neoplasias colorrectales Metástasis de la neoplasia Hepatectomía en dos etapas Vena porta Resultado del tratamiento

The Annals of Thoracic Surgery, 2008

Background. During harvest of the saphenous vein (SV), the most important relationship to take in... more Background. During harvest of the saphenous vein (SV), the most important relationship to take into account is the saphenous nerve (SN) to avoid pain and paresthesias after surgery. Methods. We harvested the SV and SN in 20 cadaveric lower limbs. Relationships between both structures were recorded using a millimetric ruler, and distances were measured from the medial malleolus at the ankle. Results. The SV was superficial to the leg fascia 32 cm above the malleolus in 95% of the legs. During its course in the leg, 40% of SNs are posterior to the SV; 40% are anterior and then posterior to the SV; and 10% are posterior and then hidden by the SV. The SN crosses the SV in 55% of the legs. Three constant branches of the SN were identified: middle-posterior, middle-anterior, and inferior-anterior. The SN ends by splitting 5.9 cm above the malleolus. A vulnerable region occurs in the lowest 13.2 cm, where the SN adheres to the SV. At this level the SN gives off the inferior-anterior branch that crosses the SV in 66% of the legs. Between 21.6 cm and 28.8 cm the SN crosses deep to the SV. Conclusions. During harvest of the SV, the most vulnerable area is the inferior third of the leg because of venonervous adhesion.

Revista Argentina de Cirugía

Santiago Cubas, 0000-0001-6026-5316; Martín Varela, 0000-0003-2376-2844; María N. Brito, 0000-000... more Santiago Cubas, 0000-0001-6026-5316; Martín Varela, 0000-0003-2376-2844; María N. Brito, 0000-0002-1394-3994; Andrés Pouy, 0000-0002-7136-144X; Nicolás D. Muniz, 0000-0002-6235-1303; Camila Haro, 0000-0003-4475-9740; Marysol Martínez, 0000-0001-8372-2006; César E. Canessa, 0000-0003-0446-7823.

SALUD MILITAR

Gastric volvulus is a rare cause for upper digestive obstruction. It is potentially lethal and re... more Gastric volvulus is a rare cause for upper digestive obstruction. It is potentially lethal and requires an urgent treatment. Its low frequency and non specific symptoms result in a late diagnosis, frequently leading to local or systemic complications. Its classic onset shows the Bortchard triad (epigastric pain, retching without vomitting and the impossibility to advance a nasogastric tube) which is observed in 70% of the patients. It is generally associated to anatomic alterations such as the hiatal hernia. A CT scan is essential to complete the etiologic diagnosis. Surgical treatment intended for gastric devolvulation and to prevent recurrences, achieves good results and can be performed through a minimally invasive procedure.

SALUD MILITAR

El leiomioma es el tumor benigno esofágico más frecuente, si bien constituye una auténtica rareza... more El leiomioma es el tumor benigno esofágico más frecuente, si bien constituye una auténtica rareza. Representa el 0,4% de todos los tumores esofágicos, muy por detrás de los tumores malignos. Es más frecuente en hombres (1,9 veces con respecto a mujeres), con un promedio de edad de 44 años, son de lento crecimiento y en ocasiones casi asintomáticos, por lo que no es raro la demora en el diagnóstico. La degeneración maligna es excepcional. Los síntomas más comunes son disfagia, dolor retroesternal, pirosis y adelgazamiento. La endoscopía y la ecoendosonografía permiten completar el diagnóstico. La cirugía está indicada en tumores sintomáticos, y el abordaje mini invasivo es la técnica de elección.

Introduction: The laparoscopic appendectomy of non-complicated acute apendicitis is a simple vide... more Introduction: The laparoscopic appendectomy of non-complicated acute apendicitis is a simple video-assisted surgery procedure. It is also possible to treat by laparoscopy those forms complicated with diffuse acute and localized peritonitis when the physician has experience in laparoscopic surgery and in the treatment of simple forms. The purpose is to show the results obtained with the laparoscopy treatment in patients with simple acute appendicitis and with peritoneal complications (diffuse and localized peritonitis). Material and methods: This Observational, retrospective, descriptive study is constituted by 148 patients treated between November, 1998 and July, 2010. Ages go from 7 to 72 years with an average of 29 years, 67 men and 81 women. 126 had non-complicated appendicitis (39 congestive, 73 phlegmonous, 13 gangrenous ones); 22 had a complicated form (14 diffuse and 8 localized peritonitis). Results: The mortality of the series was 0. Morbidity was low. A larger number of co...

RESUMEN Introduccion: La apendicectomia laparoscopica de las apendicitis agudas no complicadas es... more RESUMEN Introduccion: La apendicectomia laparoscopica de las apendicitis agudas no complicadas es un procedimiento sencillo de la cirugia videoasistida. Es tambien posible tratar por laparoscopia las formas complicadas con peritonitis difusas agudas y localizadas, cuando se tiene experiencia en cirugia laparoscopica y en el tratamiento de las formas simples. El objetivo de este trabajo es mostrar los resultados obtenidos en el tratamiento por laparoscopia de pacientes portadores de apendicitis agudas simples y con complicaciones peritoneales (peritonitis difusas y localizadas). Material y metodos: Estudio observacional, retrospectivo, descriptivo. La serie esta constituida por 148 pacientes tratados entre noviembre de 1998 y julio de 2010. Las edades oscilaron entre 7 y 72 anos con un promedio de 29 anos, 67 hombres y 81 mujeres. 126 presentaron apendicitis no complicada (39 congestivas, 73 fl emonosas, 13 gangrenosas); 22 presentaron una forma complicada (14 peritonitis difusas y 8...

Gastric cancer is the fifth most frequent malignant neoplasm worldwide and in our country, and th... more Gastric cancer is the fifth most frequent malignant neoplasm worldwide and in our country, and the fourth cause of cancer mortality. The survival rate continues to be low, since its diagnosis is usually late and in advanced stages.In countries with a high incidence, endoscopic screening is performed, making the diagnosis in early stages, with a better prognosis. In these patients there is a lower risk of regional or distant spread, and tailored treatments can be considered, avoiding wide resections.

Resección laparoscópica de schwannoma gástrico. Reporte de caso Ressecção laparoscópica do schwan... more Resección laparoscópica de schwannoma gástrico. Reporte de caso Ressecção laparoscópica do schwannoma gástrico. Relatório de caso

Acta gastroenterológica latinoamericana, 2020

Neurofibromatosis type 1, also known as von Recklinghausen disease, is an inherited neurocutaneou... more Neurofibromatosis type 1, also known as von Recklinghausen disease, is an inherited neurocutaneous disorder with gastrointestinal involvement in 5-25% of the patients, which develops following cutaneous manifestations. Only 5% have symptoms such as abdominal pain, diarrhea, palpable mass, bleeding, obstruction or intestinal perforation. There is an increased risk of developing digestive malignancies, frequently in the small bowel. The following report presents the case of a patient with neurofibromatosis type 1, with the diagnosis of a jejunal gastrointestinal stromal tumor and a fibroid inflammatory polyp in the context of gastrointestinal bleeding.

SALUD MILITAR, 2021

Una propuesta de tríada diagnóstica a propósito de un caso de oclusión por fitobezoar Uma propost... more Una propuesta de tríada diagnóstica a propósito de un caso de oclusión por fitobezoar Uma proposta para uma tríade de diagnóstico em um caso de oclusão fitobezoar

The Lancet, 2021

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little c... more Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Revista Medica del Uruguay, Sep 1, 2017

Introducción: durante muchos años se han utilizado distintos scores clínicos, paraclínicos e imag... more Introducción: durante muchos años se han utilizado distintos scores clínicos, paraclínicos e imagenológicos con el fin de predecir la morbimortalidad en la pancreatitis aguda. Dichos scores han demostrado diversa utilidad, aunque la complejidad de los mismos a la hora de su implementación ha limitado su uso en la práctica clínica habitual. Objetivo: establecer la relación del síndrome de respuesta inflamatoria sistémica (SIRS) y su duración con la mortalidad y el desarrollo de complicaciones. Material y método: se realizó un estudio multicéntrico, analítico y observacional de todos los pacientes con pancreatitis aguda (96) diagnosticados desde mayo de 2015 a mayo de 2016 en el Hospital Central de las Fuerzas Armadas (43,8%), en el Hospital de Clínicas (30,3%) y en el Hospital Español (21,9%). Resultados: el 67% de las pancreatitis agudas se desarrollaron de forma leve, 25% de forma moderada y 8% de forma severa. El 42% tenía SIRS al momento del diagnóstico y 15% mantuvieron el SIRS por más de 48 horas. El SIRS mantenido se asoció significativamente con la existencia de necrosis pancreática, falla orgánica persistente, necesidad de cuidados intensivos, presencia de complicaciones locorregionales, número aumentado de tomografías, severidad de la pancreatitis aguda y mortalidad. La mortalidad en pacientes con SIRS transitorio fue nula y con SIRS mantenido de 27%. Conclusión: el SIRS mantenido por más de 48 horas se asocia significativamente a todos los marcadores de severidad. Su ausencia o su presencia por menos de 48 horas no se asocian a mortalidad y las complicaciones locorregionales son menores.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery

Source of support: Nil Conflict of interest: None Patient consent statement: The author(s) have o... more Source of support: Nil Conflict of interest: None Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

REVISTA MEDICA DEL URUGUAY, 2019

El tratamiento de las metástasis hepáticas de origen colorrectal ha ido cambiando en estos último... more El tratamiento de las metástasis hepáticas de origen colorrectal ha ido cambiando en estos últimos 20 años. En la actualidad la cirugía constituye un pilar fundamental en el tratamiento de estos enfermos. La sobrevida de los pacientes pasibles de una resección completa del tumor puede ascender a 40% en cinco años. Estos resultados oncológicos tan alentadores han llevado a los equipos quirúrgicos a esforzarse por lograr resecciones hepáticas extremas contraindicadas en tiempos anteriores. Es, en esta línea de trabajo, que se desarrolló la cirugía de remodelación hepática que consiste en alterar el flujo portal buscando una hipertrofia del hígado sano y atrofia del enfermo. El siguiente caso pretende mostrar una de las dos cirugías de remodelación más utilizadas en el mundo, que es la hepatectomía en dos tiempos con oclusión del flujo portal. Se discute su indicación, la oportunidad de las cirugías, el beneficio oncológico y la viabilidad de su realización en nuestro medio. Palabras clave: Neoplasias colorrectales Metástasis de la neoplasia Hepatectomía en dos etapas Vena porta Resultado del tratamiento

The Annals of Thoracic Surgery, 2008

Background. During harvest of the saphenous vein (SV), the most important relationship to take in... more Background. During harvest of the saphenous vein (SV), the most important relationship to take into account is the saphenous nerve (SN) to avoid pain and paresthesias after surgery. Methods. We harvested the SV and SN in 20 cadaveric lower limbs. Relationships between both structures were recorded using a millimetric ruler, and distances were measured from the medial malleolus at the ankle. Results. The SV was superficial to the leg fascia 32 cm above the malleolus in 95% of the legs. During its course in the leg, 40% of SNs are posterior to the SV; 40% are anterior and then posterior to the SV; and 10% are posterior and then hidden by the SV. The SN crosses the SV in 55% of the legs. Three constant branches of the SN were identified: middle-posterior, middle-anterior, and inferior-anterior. The SN ends by splitting 5.9 cm above the malleolus. A vulnerable region occurs in the lowest 13.2 cm, where the SN adheres to the SV. At this level the SN gives off the inferior-anterior branch that crosses the SV in 66% of the legs. Between 21.6 cm and 28.8 cm the SN crosses deep to the SV. Conclusions. During harvest of the SV, the most vulnerable area is the inferior third of the leg because of venonervous adhesion.