A knowledge of the blood supply of the normal biliary system and the collateral hilar plate arterial plexus forms the anatomical foundation for successful reconstructive surgery, not only in vasculobiliary injuries following cholecystectomy, but also for a wide range of hepatobiliary procedures.

The satisfactory results of end-to-end anastomosis in whole liver transplantation depends partly on the presence of adequate venous drainage. This has been amply demonstrated by the injection studies. This would indicate that the poor results of end-to-end repair of the bile duct after surgical trauma results from other factors such as poor technique, devascularization of the cut ends due to trauma, and carrying out the anastomosis under tension. After resection of the hilum for cholangiocarcinoma the venous drainage of the left and right hepatic ducts and their branches depends mainly on the communications between the venous plexus on the ducts and the adjacent branches of the portal vein, even at a lobular or sinusoidal level. The satisfactory results obtained after anastomosis of the left and right hepatic ducts or their branches to a Roux loop ofjejunum attest to this. This applies also to the transplantation of segments II and III in paediatric patients from related adult donors and in patients receiving split liver transplants. Finally, the venous drainage at the bifurcation of the common hepatic duct has been shown to enter the caudate lobe and segment IV directly. This suggests that a hilar cholangiocarcinoma may metastasize to these segments, and perhaps partly explain the significantly better long-term results when the caudate lobe and segment IV are resected en bloc with the cholangiocarcinoma as part of modern radical surgery for this condition.

Thomas Peel Dunhill, a name by now almost completely forgotten in his native Australia, was born in 1876 near Kerang in the State of Victoria. Although he qualified as a pharmacist in 1898, Dunhill had already decided to study medicine and graduated in 1903 from the Clinical School of the Melbourne Hospital. He was regarded as an outstanding student. In 1905 Dunhill was invited to join the Senior Medical Staff at St Vincent's Hospital by Mother Berchmans Daly, the then Mother Rectress. In 1906 Dunhill was awarded the MD and in 1907 he performed his first thyroid lobectomy under local anaesthesia for toxic goitre. As early as 1908, Dunhill understood the essentials for successful surgery in thyrotoxicosis--enough thyroid had to be removed to cure the condition. To this end, he advocated a bilateral attack on the thyroid and advocated thyroidectomy in the thyrocardiac patient. He did this before Theodor Kocher, Charles Mayo, William Halsted or George Crile. In 1911 Dunhill visited the USA and England and communicated his results to the thyroid surgeons in both countries (230 cases of exophthalmic goitre operated on with four deaths). The English could not, or would not, believe his results as the mortality of surgery for exophthalmic goitre at St Thomas's Hospital, London in 1910 was 33%. Dunhill served with distinction in the Great War and his abilities favourably impressed George Gask, who was to become the Professor of Surgery at St Bartholomew's Hospital, London. Gask eventually invited Dunhill to join his Unit and Dunhill left St Vincent's Hospital in 1920. Between 1920 and Dunhill's retirement at the age of 60 in 1935, he became the outstanding general surgeon at St Bartholomew's Hospital. Dunhill and Cecil Joll, were regarded as the leading thyroid surgeons in the UK. Knighted in 1933, Dunhill was appointed surgeon to the Royal Household, serving four British monarchs. In addition to his brilliant surgical career, Dunhill maintained a love for the land. He was an expert fly fisherman. Dunhill retired from surgical practice in 1949 and died at the age of 80 in 1957 at his London home. Many eulogies were delivered, especially by Sir James Paterson Ross and Sir Geoffrey Keynes, his former pupils. Dunhill's exploits as a thyroid surgeon in the development of a safe and effective treatment for thyrotoxicosis and in operating on the thyrocardiac enables this modest, courteous and loyal Australian to be included with Theodor Kocher, Charles Mayo, William Halsted and George Crile in the pantheon of pioneer thyroid surgeons.

Background:The majority of patients who require palliation for jaundice and pruritus resulting from malignant hilar obstruction are treated by stenting. Stenting is usually achieved from below after performing an endoscopic retrograde cholangiopancreatography. In some cases the rendezvous technique is employed, negotiating the passage through a malignant stricture from above and stenting from below. A minority of cases, such as those who had a previous polyagastrectomy and those in whom attempts at stenting have failed, are considered to be suitable for a Segment 111 cholangiojejunostomy. We have investigated the anatomical basis for Segment 111 duct bypass and have critically analysed the results in 13 patients. Ten patients were treated by Segment 111 duct bypass alone, and three patients had a Segment 111 duct bypass combined with stenting of the right liver. Methods: The anatomy of the biliary tree was investigated by dissection of 54 normal livers removed at autopsy. Clinical details of the 13 patients who had Section 111 cholangiojejunostomy were obtained from hospital records and by contacting treating practitioners. Results: In 64.8% of the anatomical dissections, the findings were favourable for a Section I11 cholangiojejunostomy. In these specimens the Segment 111 duct bypass would have drained Segments 11,111 and IV. In 35.2% of the specimens the anatomical disposition was potentially unfavourable, mainly due to the Segment I1 or IV ducts joining close to the confluence and therefore liable to obstruction by the tumour. In nine of the 54 specimens the true left hepatic duct was less than 6 mm in length, making it unsuitable for a bypass procedure to drain the left hemi liver. Of the 10 patients who were subjected to a palliative Section 111 cholangiojejunostomy only, there was one postoperative death. Of the nine patients who survived, six obtained excellent palliation of jaundice and pruritus. Conclusions: In carefully selected cases, Section III cholangiojejunostomy achieves excellent palliation in patients with unresectable hilar malignancies that have been unable to be stented pre-operatively or who have unresectable tumours at the time of laparotomy .

A 57‐year‐old woman was investigated for obstructive jaundice with endoscopic retrograde cholangiopancreaticography that showed a tumor at the ampulla of Vater. A Whipple's procedure was performed. A protuberant tumor was present at the ampulla of Vater in the background of multiple mucosal polyps in the duodenum. Light microscopy revealed a diffuse non‐Hodgkin's lymphoma with centrocytelike cells forming lymphoepithelial lesions and infiltrating the sphincter of Oddi. The duodenal polyps were hyperplastic lymphoid follicles with reactive germinal centers. Immunohistochemical staining characterized the tumor as a B‐cell neoplasm with IgA heavy‐chain and lambda light‐chain restrictions. Complete remission of the disease occurred after surgery. The clinical, histologic, and immunohistochemical features of this lymphoma are suggestive of histogenetic derivation from mucosal‐associated tissue.

Background:The usual methods of closure of major chest and abdominal wall defects have significant disadvantages. Skin grafts provide no structural support and result in incisional hernias. Synthetic mesh requires skin cover and is prone to infection and wound breakdown. The tensor fasciae latae (TFL) myocutaneous flap offers skin cover and a semi-rigid fascial layer. We document our unit's experience in pedicled and free TFL flaps. Methods: The TFL flap closure of trunk defects was undertaken in 10 patients between August 1989 and April 1997. All cases were not amenable to primary closure and repair with synthetic mesh or skin grafts. Results: The defect was satisfactorily repaired in all cases without subsequent herniation. Tne closure techniques using a pedicled TFL flap and a TFL flap for a free-tissue transfer are described. Conclusions: We conclude that the TFL flap is the method of choice for repairs of major truncal defects.

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The experience of acute mesenteric ischæmia at St Vincent's Hospital, Melbourne, has been reviewed over 17 years. The mortality remains appallingly high. This applies particularly to those patients who had thrombosis of the superior mesenteric artery, amongst whom the mortality in this series was 97%. The mortality was slightly less in the group suffering from embolic occlusion of the superior mesenteric artery (66%), and in those suffering from thrombosis of the superior mesenteric vein (60%). A mortality of 66% was also found in patients suffering from non‐occlusive gut ischæmia. Delay in diagnosis accounted for this high mortality. Early diagnosis is all‐important, and this depends on the performance of mesenteric angiography in any patient suspected of having mesenteric ischæmia. Appropriate surgery may then be carried out in the occlusive group and supportive treatment, including intraarterial papaverine infusion, given to those with non‐occlusive ischæmia. There is a pressing need for simple non‐invasive tests to segregate those patients suffering from acute mesenteric ischæmia from those whose acute abdomen is due to some other cause.