Rare Anatomical Variation Research Articles

Pulsatile hemorrhage posterior to the mandibular third molar due to abnormal branching of the inferior alveolar artery: A case report

AbstractBackgroundThe retromolar canal and foramen posterior to the mandibular third molar are rare anatomical variants through which branches of the inferior alveolar neurovascular bundle may pass.Case PresentationPulsatile hemorrhage occurred when the removal of a mandibular third molar and a surrounding cystic lesion was attempted in a 56‐year‐old woman. On imaging, well‐developed inferior alveolar artery branch was observed in the retromolar canal, and the facial artery could not be identified on the same side.ConclusionClinicians must be aware of this anatomical variant to avoid complications.

A rare anatomical variant: Aberrant arterial supply of azygoesophageal recess originating from the celiac plexus

A rare anatomical variant: Aberrant arterial supply of azygoesophageal recess originating from the celiac plexus

A Rare Anatomic Variant during Organ Procurement for Liver Transplantation

A Rare Anatomic Variant during Organ Procurement for Liver Transplantation

A very rare case of a subhepatic appendix of 20cm length in a girl.

A 6-year-old girl was consulted for an appendicular syndrome that had been evolving for 3 days. The clinical examination revealed a febrile child with a temperature of 39°C and a tacchycardia. Abdominal examination revealed right hypochondrium defense and deep tenderness of the right flank and right iliac fossa. The biological work-up showed a predominantly neutrophilic hyperleukocytosis. Abdominal ultrasound revealed a subhepatic appendix 9 mm in diameter associated with a well-limited hypoechoic collection in the right hypochondrium 4 cm in length with no obvious stercolith. Surgical exploration revealed a sub-hepatic and subserosal appendix of 20 cm in length, which is a very rare anatomical variant and underlines the need to verify the convergence of the 3 caecal bands to determine the exact site of the appendicular base. The risk is to leave an appendicular stump in place.

Surgical Treatment of Distal Radius Fractures Complicated by Concomitant Flexor Carpi Radialis Brevis: A Case Series and Surgical Techniques.

The flexor carpi radialis brevis (FCRB) is a rare anatomical variation, with a reported prevalence ranging from 0.9% to 8.7%. Our previous report showed three cases of FCRB in distal radius fracture (DRF) and found that hypoplastic pronator quadratus (PQ) adjacent to the FCRB muscle made it difficult to cover a volar locking plate (VLP). As we subsequently experienced additional six FCRBs, we report on new findings and surgical tips. VLP fixation was performed on DRF with FCRB in nine limbs of eight patients. The prevalence was 2.9% (9 of 310 limbs). Of the seven patients that underwent unilateral surgery, six were muscle type and one was tendon type. One patient who underwent bilateral surgery had a muscle type on the left and a tendon type on the right. In three muscle types, as the FCRB muscle belly was widely attached to the radial side of the radius and the radial side of the PQ was hypoplastic, postoperative covering of the plate by repair of the PQ was impossible. Then, in two of those cases, the PQ and FCRB were sutured and the plate was covered. FCRB muscle could be retracted to the radial side in all cases. One patient with a tendon type had a ruptured tendon, which was left unrepaired. All patients had no postoperative problems. In the muscle-type FCRB, the muscle should be retracted to the radial side for VLP fixation. The muscle belly might occupy the radial side of the radius, and the PQ might be hypoplastic and unrepairable. However, the plate can be covered by suturing the PQ and FCRB.

Rare complex anatomical variation of right pulmonary vessels and bronchi: a case report

Rare complex anatomical variation of right pulmonary vessels and bronchi: a case report

Aneurysmal dilatation of vein of galen associated with thalamic arteriovenous malformation and straight sinus agenesis

Straight sinus agenesis is a rare congenital anatomical variation that is usually accompanied by persistent falcine sinus. Concomitance of straight sinus agenesis and absence of falcine sinus are associated with thalamic arteriovenous malformation by the disturbance of the venous flow. In this report, a very rare case of aneurysmal dilatation of the vein of Galen associated with thalamic arteriovenous malformation and straight sinus agenesis is presented.

Anomalous mediastinal left lower lobe anterior segmental artery (A8) accidentally divided during left VATS upper lobectomy: a case report

: Bronchovascular anatomical variations can pose technical challenges during lobectomy and especially segmentectomy where these structures are embedded deep in the lung parenchyma. Familiarity with these anatomical variations helps avoid intraoperative injury and accidental division. Mediastinal origin of left upper lobe apicoposterior (truncus superior) and lingula arterial branches (A4+5) is common. However mediastinal origin of left lower lobe segmental pulmonary branches is very rare and has not been reported in the literature. An anomalous mediastinal origin of left lower lobe anterior segmental artery (A8) noted during a left video-assisted thoracic surgery (VATS) upper lobectomy in a 69 years old male with stage 1 lung cancer is described. The artery was mistaken for a mediastinal lingula branch (A4+5) during surgery and was divided accidentally. The injury was recognised intraoperatively and primary end to end vascular repair was done by VATS, with the patient making an uneventful recovery. Awareness of this rare anatomical variant can help prevent intraoperative vascular injury or accidental ligation during left VATS lobectomy. Injuries due to anomalous bronchovascular anatomical variations can be prevented by preoperative planning by 3-dimensional contrast enhanced computer tomography and by careful intraoperative dissection and identification of mediastinal and interlobar vessels distally into the respective segments before ligation.

Cloacal Malformation with Associated Urethral Atresia

Introduction Cloacal malformations comprise a heterogeneous group of anomalies that are considered the most complex anorectal malformations (ARMs) in females. Precise evaluation to identify the unique anatomy prior to reconstruction with collaboration between colorectal surgeons, urologists, and gynecologists is vital. Here, we present a rare anatomical variation in a patient with a cloacal malformation which affected operative and postoperative management. Case description A 6-year-old female with cloaca who underwent colostomy, vaginostomy, and vesicostomy as a newborn presented for reconstruction. Her VACTERL workup was negative except for an atretic right kidney. Her ARM index included the cloaca, a normal spine, and sacrum with a lateral sacral ratio of 0.7, predicting good potential for bowel continence. Cystoscopy through the vesicostomy showed a small bladder with normal ureteral orifices, and a closed bladder neck, with no identifiable urethra. A cloacagram showed an atretic common channel, a single small vagina, and a rectum below the pubococcygeal line. The patient underwent a posterior sagittal anorectovaginourethroplasty, vaginal patch using rectum, rectoplasty, and perineal body reconstruction. The urethra was not amenable to reconstruction, so the vesicostomy was preserved and a future Mitrofanoff was planned. Conclusion Urethral atresia is a rare and challenging finding in cloaca patients, and a vesicostomy is needed to drain urine in the newborn period. Preoperative examination under anesthesia, cystoscopy, vaginoscopy, and cloacagram are crucial to identify the precise anatomy and to plan accordingly.

A Rare Anatomical Variation of Upper Multiple Impacted Third Molar

Abstract The third molar is the most commonly impacted tooth which is the cause of pain and discomfort in the second and third decade of life. Therefore, it is the commonly carried out minor surgical procedure which helps remove the cause of discomfort and pain. However, few cases may show no related signs and symptoms and such multiple impacted tooth is found accidently on radiographic findings. This can be removed to avoid discomfort or pain or any pathology in the subsequent period of time. In this case report, we discuss about the multiple impacted upper third molar in a patient, which showed a unique anatomical variation.

Thick moderator band in the right ventricle of a horse: an accidental finding

The purpose of this case report is to describe and document a rare anatomical variation of a moderator band located in right ventricle of a stallion referred for cryptorchid castration. During routine pre-anesthetic echocardiography, a thick moderator band was detected crossing the right ventricle. No other cardiovascular abnormalities were identified. Anesthesia and recovery occurred uneventfully. This variation is important not only for anatomy but also for the evaluation of normal heart both during ultrasound and electrocardiographic examination.

Incidence of "<em>Caterpillar hump</em>" of right hepatic artery in the "<em>Calot triangle</em>" among a selected population in Sri Lanka. A chart review

Introduction: "Caterpillar hump" of the right hepatic artery in the triangle of Calot, is a rare variation that increases the risk of vascular and biliary injuries during laparoscopic cholecystectomy. This study aims to determine the prevalence of right hepatic artery forming "Caterpillar hump" in a selected cohort of patients who underwent laparoscopic cholecystectomy in a private hospital in Sri Lanka.Methods: A retrospective chart review was conducted to determine the prevalence of "Caterpillar hump" of the right hepatic artery among patients who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis in a private hospital in Colombo, Sri Lanka, from 2015 to 2022. Data were retrieved from the available records at hospitals from 2015 to 2022. There were 79 patients recode during the study period. These records consist of manually written bed head charts, discharge summaries and electronic medical records. Patient records which did not clearly mention the Calot triangle vasculature or illegible handwriting were excluded from the study. Out of that, only 75 [94.9%] patients' charts were eligible for the study. Data on demographic and Calot triangle vasculature was recorded during surgery and retrieved from the hospital records. Ethical approval for the study was obtained from the hospital's ethical committee.Results: Among the patients who underwent laparoscopic cholecystectomy, 50 (66.7%) were female, and 25(33.3%) were male patients, with a mean (±SD) age of 57.4±4.8 years (range 18–81). The prevalence of the "Caterpillar hump" right hepatic artery in the calot's triangle among the study sample was 4 % ( 3/75). Two were females and one male. In all cases, the vascular variation was reported in a single-loop fashion, and no double-loop configuration was noted.Conclusions: This study showed that the right hepatic artery was subjected to this rare anatomical variation. This anomalous presentation increased the risk of vessel ligation or injury during laparoscopic Cholecystectomy. Thus, the awareness of caterpillar hump within Calot triangle, during surgical procedures is useful.

A rare anatomical variation of the hand lumbrical muscles: A case report and literature review

We report a case of unusual anatomical variation and rare abnormality of the lumbrical muscles (LM) in a cadaver after dissection. Usually, the hand LM arises from the flexor digitorum profundus (FDP) tendons and inserts into the extensor hoods of the corresponding fingers. LM is fundamental in the performance of fine skillful movements of the hand.

986 LEFT VENTRICULAR LEAD PLACEMENT FOR BIVENTRICULAR PACING INTO A LEFT LATERAL VEIN IN PATIENT WITH CONGENITAL ATRESIA OF THE CORONARY SINUS OSTIUM WHO UNDERWENT AORTIC VALVE REPLACEMENT

Abstract Introduction Coronary sinus ostial atresia (CSOA) is a rare congenital heart anomaly consisting in the occlusion of the coronary sinus (CS) outlet in the right atrium. It is one of the causes of placement left lead failure in CS during cardiac resynchronization therapy (CRT) device implantation. The persistence of the left superior vena cava is the most common pathway that allows venous blood flow to drain into the right atrium and can represent a new possible way to reach a left ventricular vein from the CS. Methods A 66-year-old male suffering from sarcoidosis was studied after an episode of syncope under exertion. EKG showed a 1st degree atrioventricular block and a left bundle branch block (LBBB) with wide QRS (170 ms). Echocardiography found left ventricle dilatation, severe systolic dysfunction, and a severe low-flow low-gradient aortic stenosis for which he underwent aortic valve replacement. After surgery and finding of 2nd degree type II atrioventricular block, CRT implant was performed but the procedure was complicated by the finding of CSOA. The insertion of the left quadripolar lead along a left branch of the occluded CS was achieved with a push-and-pull technique of the lead over a guidewire, after the retrieval and the cannulation of the persistent left superior vena cava. Results A new approach was applied on a rare case of CSOA found during CRT procedure. The contrast medium (CM) in the left subclavian vein revealed the existence of the left superior vena cava that was than cannulated. CM injection in CS highlighted a posterior left branch that was approached with a specific guidewire and a subselector after selective venography. With a fine technique of sliding of the lead on a tensioned guidewire, the quadripolar catheter was successfully placed in the left ventricular vein. Left-ventricle-right ventricle delays and catheter thresholds were tested and a final QSR duration of 90 msec in CRT mode was obtained. Conclusions This case-report shows a complex technique, reported in parallel with other similar procedures, to help the approach toward a rare anatomical variant of CSOA accompanied by persistent left superior vena cava when a CRT implant is needed after cardiac valve surgery in a patient suffering from sarcoidosis.

갑상선 절제술 중 발견된 단일 신경 가지처럼 보였던 반회후두신경 분지 증례 1예

The recurrent laryngeal nerve (RLN) is an important structure that requires careful attention to be preserved during thyroidectomy. Because injury of this nerve results in vocal cord paralysis, which can lead to voice change, aspiration and even pneumonia. RLN often has branches which is vulnerable to nerve injury during surgery. RLN branch usually occurs close to the cricothyroid joint, or close to the junction between the nerve and the inferior thyroid artery. However, if the RLN branch is located lower than inferior thyroid artery, the risk of nerve damage could be increased. We report this rare anatomic variation of RLN case with a review of the literature.

Duplication of the internal maxillary artery: Anatomical and clinical considerations.

Duplication of the internal maxillary artery (IMAX) results from a failed regression of either the embryological superficial or deep ring and is reported to be exceedingly rare. We present a patient with this rare anatomical variant who was treated by endovascular technique in the clinical context of an acute oropharyngeal hemorrhage.

Successful management of ectopic kidney stones in a patient with situs inversus totalis: a rare case report

BackgroundSitus inversus totalis is a very rare congenital anatomical variation, in which all thoracic and abdominal organs are right-left inverted. This condition is associated with an increased risk of organ malformations including ectopic kidney, which is a very rare combination.Case presentationA 56-year-old male presented with colicky left iliac pain associated with nausea, vomiting, and irritative lower urinary symptoms. The patient has a medical history of recurrent lower urinary infections and a family history of situs inversus totalis. Radiological images demonstrated dextrocardia, situs inversus totalis of all the abdominal organs, and an ectopic pelvic kidney on the left side, with 4 stones inside it. Left nephrectomy was performed due to extensive renal damage. At discharge and during follow-up, the patient's condition was satisfactory and stable.ConclusionsThe ectopic kidney may present diagnostic and therapeutic challenges when associated with situs inversus.

Intraspinal Azygos Vein

Teaching Point: Intraspinal azygos vein is an extremely rare anatomical variant; knowledge is important for correct imaging interpretation.

Intraoperative Finding of Anomalous Circumflex Artery Origin in the Dissected Right Coronary Ostium.

Anomalous origin of the left circumflex artery is a rare anatomical variant that may present a unique challenge in emergent aortic surgery.

S2963 Congenital Riedel’s Lobe of the Liver: A Case Report

Introduction: Riedel lobe of the liver is a rare anatomical variation with a reported incidence to be between 3.3% and 14.5%. We report a case of a 43-year-old female with an incidental finding of non-palpable Riedel’s lobe. Case Description/Methods: A 43-year-old female was referred for evaluation of hepatomegaly, which was revealed on MRI and CT scan dating back to 2016. Medical history notable for Irritable Bowel Syndrome (IBS), uterine fibroids, and a history of a tumor removal from her right breast. Patient denies any history of alcohol, illicit drugs, hepatotoxic medications, or pre-existing liver disease. Physical exam was unremarkable and abdominal exam did not reveal any mass or abnormalities. Routine blood examination, including LFTs and iron studies, was within normal limits. Hepatitis panel (A, B, C), anti-smooth muscle antibody, and LKM-1 IgG antibody was negative. ANA, alpha-1 antitrypsin, and tissue transglutaminase were all negative. The only lab abnormality was an elevated IgG mitochondrial M2 antibody 54.5 (normal less than 20 units). CT abdomen was significant for an enlarged liver with the right lobe extending into the pelvis and ‘not completely included in the study’. MRI abdomen revealed a markedly enlarged liver measuring up to 23.8cm in its craniocaudal dimension with extension into the pelvis with the pancreas deviated to the left, likely secondary to the prominent hepatomegaly. Venous duplex significant for normal directional flow in the portal and hepatic veins with no evidence of portal hypertension. Liver biopsy revealed signs of sinusoidal dilatation nonspecific for veno-occlusive outflow obstruction with no signs of inflammation, steatosis, or fibrosis. The patient was diagnosed with Riedel’s lobe of the liver. She was discharged from the hospital without treatment with a recommendation to repeat an MRI in 1 year, as torsion is a reported complication of Riedel’s lobe over time. Patient will be recommended to repeat LFTs and anti-mitochondrial antibody to determine progression/significance prior to follow up in 6 months. Discussion: Riedel’s lobe of the liver is a rare anatomical variant that is often incidentally found on imaging or the presence of hepatomegaly on physical exam. Although patients are usually asymptomatic, its presentation can vary, ranging from nonspecific symptoms to more severe symptoms such as torsion, obstruction, rupture, and bleeding. The range of symptoms highlights its importance in diagnosis and surveillance in this patient population.Figure 1.: (A) CT of the abdomen/pelvis from 2016. Liver measuring up to 197.3mm in the sagittal plane. (B) CT of the abdomen/pelvis from 2020. Liver measuring up to 215.4mm in the sagittal plane.