Surgical Anatomy Research Articles

The lateral retrocanthal transorbital endoscopic approach to the middle fossa: cadaveric stepwise approach and review of quantitative cadaveric data.

The lateral retrocanthal transorbital endoscopic approach (LRCTEA) facilitates trajectory to the middle fossa, preserving the lateral canthal tendon and thus avoiding postoperative complications such as eyelid malposition. Here, the authors sought to define the surgical anatomy and technique of LRCTEA using a stepwise approach in cadaveric heads and offer an in-depth examination of existing quantitative data from cadaveric studies. The authors performed LRCTEA to the middle cranial fossa under neuronavigation in 7 cadaveric head specimens that underwent high-resolution (1-mm) CT scans preceding the dissections. The LRCTEA provided access to middle fossa regions including the cavernous sinus, Meckel's cave, and medial temporal lobe. The trajectories and endpoints of the approach were confirmed using electromagnetic neuronavigation. A stepwise approach was delineated and recorded. The authors' cadaveric study delineates the surgical anatomy and technique of the LRCTEA, providing a stepwise approach for its implementation. As these approaches continue to evolve, their development and refinement will play an important role in expanding the surgical options available to neurosurgeons, ultimately improving outcomes for patients with complex skull base pathologies. The LRCTEA presents a promising advancement in skull base surgery, particularly for accessing challenging middle fossa regions. However, surgeons must remain vigilant to potential complications, including transient diplopia, orbital hematoma, or damage to the optic apparatus.

Use of minimally invasive ultrasound transducer during tubular microdiscectomy.

Minimally invasive ultrasound during tubular microdiscectomy is novel. The authors report the technique during surgery for L5-S1 herniated disc. Ultrasound provided real-time visualization of the pathology and neural elements. After discectomy and tactile assessment, ultrasound showed decompression of the thecal sac and traversing nerve root. The patient tolerated the procedure well, with resolution of preoperative pain and strength improvement. Postoperative MRI revealed a residual asymptomatic disc fragment that was retrospectively identified on ultrasonography. Minimally invasive ultrasound could become a useful supplement to direct visual and tactile assessment during tubular microdiscectomy, but further experience with surgical anatomy on ultrasound is required. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23206.

360° around the orbit: key surgical anatomy of the microsurgical and endoscopic cranio-orbital and orbitocranial approaches.

Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit. Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described. Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa. This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.

Kidney collecting system anatomy applied to endourology - a narrative review.

To evaluate the surgical anatomy of the kidney collecting system through a narrative review of the literature, highlighting its importance during diagnosis and its approach during surgical procedures for the treatment of renal stones. We carried out a review about the anatomy of the kidney collecting system. We analyzed papers published in the past 40 years in the databases Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials and opinions of specialists. Renal collecting system could be divided in four groups: A1 - kidney midzone (KM), drained by minor calyx that are dependent on the superior or the inferior caliceal groups; A2 - KM drained by crossed calyx, one draining into the superior caliceal group and another draining into the inferior caliceal group; B1 - KM drained by a major caliceal group independent of both the superior and inferior groups; and B2 - KM drained by minor calyx entering directly into the renal pelvis. Some details and anatomic variations of the collecting system are related to clinical and radiological aspects, particularly perpendicular calyces, interpyelocalyx space, position of calyces in relation to renal border, classification of the renal collecting system, infundibular diameter and the angle between the lower infundibulum and renal pelvis. The knowledge of intra-renal collecting system divisions and variations as the angle between the renal pelvis and lower infundibula, position of the calices in relationship with renal edge and the diameter and position of the calyces are important for the planning of minimally invasive renal surgeries.

880 Extraction of a Metal Arrow Entering the Skull Base Using a Three-Surgeon Combined Microscopic and Endoscopic Approach

INTRODUCTION: Low velocity penetrating brain injuries (PBI) present both a diagnostic and therapeutic challenge in management particularly in operative planning for the extraction of the impaled foreign body. METHODS: A 3-surgeon combined microscopic-endoscopic approach with the use of intraoperative ultrasound, angiogram, and C-arm localization was done. This involved a 5-part procedure: internal carotid angiography; parieto-occipital vertex craniotomy with ultrasound-guided localization; right transciliary cranio-orbito-zygomatic osteotomy transciliary approach; endoscopic guided advancement and extraction of foreign body and endoscopic endonasal transsphenoidal repair of skull base defect. RESULTS: The rationale for the procedures borders on obtaining information on the relationship of the arrow to the major vessels at the base of the brain, visualization of the arrow’s entry into the skull, guidance on the point of exit as the arrow was pushed upwards towards cortex and extracted it from the surface, and the integrated use of a basal approach for actual visualization of the shaft of the arrow. The patient remained clinically and neurologically stable post-operatively and was discharged after 10 days. He was back to pre-morbid functional status during follow-up at the outpatient two weeks after surgery. CONCLUSIONS: Presented is a successfully managed case of low-velocity PBI. The knowledge of surgical anatomy combined with the different concepts and principles of neurosurgery led to the development of combined techniques that can be used and may further be improved in the management of these injuries.

Surgical Anatomy of the Retrosigmoid Approach With Transtentorial Extension: Protecting the 4th Cranial Nerve.

The retrosigmoid approach with transtentorial extension (RTA) allows us to address posterior cranial fossa pathologies that extend through the tentorium into the supratentorial space. Incision of the tentorium cerebelli is challenging, especially for the risk of injury of the cranial nerve (CN) IV. We describe a tentorial incision technique and relevant anatomic landmarks. The RTA was performed stepwise on 5 formalin-fixed (10 sides), latex-injected cadaver heads. The porus trigeminus's midpoint, the lateral border of the suprameatal tubercle (SMT)'s base, and cerebellopontine fissure were assessed as anatomic landmarks for the CN IV tentorial entry point, and relative measurements were collected. A clinical case was presented. The tentorial opening was described in 4 different incisions. The first is curved and starts in the posterior aspect of the tentorium. It has 2 limbs: a medial one directed toward the tentorium's free edge and a lateral one that extends toward the superior petrosal sinus (SPS). The second incision turns inferiorly, medially, and parallel to the SPS down to the SMT. At that level, the second incision turns perpendicular toward the tentorium's free edge and ends 1 cm from it. The third incision proceeds posteriorly, parallel to the free edge. At the cerebellopontine fissure, the incision can turn toward and cut the tentorium-free edge (fourth incision). On average, the CN IV tentorial entry point was 12.7 mm anterior to the SMT base's lateral border and 20.2 mm anterior to the cerebellopontine fissure. It was located approximately in the same coronal plane as the porus trigeminus's midpoint, on average 1.9 mm anterior. The SMT and the cerebellopontine fissure are consistently located posterior to the CN IV tentorial entry point. They can be used as surgical landmarks for RTA, reducing the risk of injury to the CN IV.

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group).

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhancedCT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Endoscopic endonasal decompression of the optic nerve in the setting of compressive lesions: how I do it.

Many lesions in the anterior skull base may compress the optic nerve (ON), leading to vision loss, and even irreversible blindness. Although decompression of the optic nerve has traditionally been achieved transcranially, the endoscopic endonasal approach (EEA) is gaining traction as a minimally invasive approach recently. We describe the key steps of an EEA ON decompression. The relevant surgical anatomy with illustration is described. Additionally, a video detailing our technique and instruments on an illustrative case is provided. Endoscopic endonasal approach ON decompression with a straight feather blade is a feasible, minimally invasive procedure to decompress the ON in the setting of anterior skull base mass lesions.

SCALP COMPLICATIONS OF CRANIOFACIAL SURGERY: A COMPREHENSIVE SYSTEMATIC REVIEW

Methods: By the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. This search approach, publications that came out between 2014 and 2024 were taken into account. Several different online reference sources, like Pubmed, SagePub, and Google Scholar were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search get 21 articles, whereas the results of our search on SagePub get 87 articles, on Google Scholar 2350 articles. Records remove before screening are 1983, so we get 475 articles fos screening. After we screened based on record exclude, we compiled a total of 10 papers. We included five research that met the criteria. Conclusion: For craniofacial surgery, understanding the surgical anatomy, identifying risk factors, adequate surgical planning, and interdisciplinary cooperation between neurosurgeons, plastic surgeons, and the interdisciplinary team are essential to prevent and treat scalp complications.

Efficacy and safety of endoscopic ultrasound-guided hepatico-gastrostomy: a meta-regression analysis.

EUS-guided hepaticogastrostomy (EUS-HGS) is a valid option for EUS-guided biliary drainage that has been increasingly used in the last decade. The aims of the study were to provide a systematic review with meta-analysis and meta-regression of features and outcomes of this procedure. MEDLINE, Scopus, Web-of-Science, and Cochrane databases were searched for literature pertinent to EUS-HGS. Meta-analysis of proportions and meta-regression of potential modifiers of the main outcome measures were applied. The main outcome was technical success. Secondary outcomes were clinical success and procedure-related adverse events (AEs). Thirty-three studies including 1644 patients were included in the meta-analysis. Malignant biliary obstruction was the underlying cause in almost all (99.6%) cases; the main indications for EUS-HGS were duodenal/papillary invasion (34.8%), surgical altered anatomy (18.4%) and hilar stenosis (16%). Pooled technical success of EUS-HGS was 97.7% (95%-CI: 96.1-99%, I2=0%), the intention to treat (ITT) clinical success was 88.1% (95%-CI: 84.7-91.2%, I2=33.9%) and procedure-related AEs occurred in 12% (95%-CI: 9.8-14.5%, I2=20.4%), being cholangitis/sepsis (2.8%) and bleeding (2.3%) the most frequent. The rate of procedure related AEs was reduced with the use of dedicated stents at the univariable meta regression analysis. Meta-regression showed that technical success and clinical success rates were modified by centers' experience (>4/year). EUS-HGS represents an effective and safe procedure for EUS-guided biliary drainage in patients with malignant biliary obstruction. Future studies should address the impact of center experience, patient selection, and use of dedicated stents to improve this technique's performance.

A Global Bibliometric and Visualization Analysis of Craniovertebral Junction Bony Abnormalities Based on VOSviewer and Citespace

ObjectiveRecent years have witnessed a rapidly growing interest in CVJ bony abnormalities, and a qualitative and quantitative analysis of relevant literatures is necessary. This study aims to identify and summarize the published articles related to craniovertebral junction bony abnormalities, to analyze and visualize the current research trends and major contributors. MethodsWe collected data from Web of Science, excluding certain article types. Two researchers screened articles for relevance. Data was organized with EndnoteX9, and analyzed using VOSviewer and CiteSpace for co-authorship, co-occurrence, keyword burst, and co-citation analyses to identify research trends and collaborations. ResultsA total of 2,776 articles were included, revealing an increasing trend in annual publications of CVJ bony abnormalities. The USA was the leading country. King Edward Memorial Hospital was the most prolific institution, and Seth GS Medical College had the most citations. The Spine is the most popular journal with the highest number of publications and citations. Professor Goel Atul from India emerged as the most influential pioneer in this field. Keyword analysis highlighted surgical techniques, diagnosis, and anatomy as the primary research hotspots and Fixation, Placement, and Basilar invagination gradually become the new research trend. However, there is a relative weakness in basic research and epidemiology. ConclusionThis study provides valuable insights into the current research trends and critical contributors in CVJ bony abnormalities, guiding evidence-based decisions and fostering international collaborations to advance knowledge in this field.

Value of the surgical pancreatic duct anatomy and associated outcomes in pancreatic cancer.

Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy are frequent but often underestimated. This study aimed to investigate the potential importance of these variations in outcomes and patient survival after Whipple's procedures. Data were collected from 105 patients with confirmed pancreatic head neoplasms who underwent surgery between 2008 and 2020. Radiological measurements of pancreatic duct location were performed, and statistical analysis was carried out using IBM SPSS. Inferior pancreatic duct topography was associated with an increased rate of metastatic spread and tumour recurrence. Additionally, inferior duct topography was associated with reduced overall and recurrence-free survival. Posterior pancreatic duct topography was associated with decreased incidence of perineural sheet infiltration and improved overall survival. These findings suggest that topographical diversity of pancreatic duct location can impact outcomes in Whipple's procedures. Intraoperative review of pancreatic duct location could help surgeons define areas of risk or safety and deliver a personalized surgical approach for patients with beneficial or deleterious anatomical profiles. This study provides valuable information to improve surgical management by identifying high-risk patients and delivering a personalized surgical approach with prognosis stratification.

Surgical anatomy of superior gluteal artery in relation to lumbosacral plexus – A cadaveric study in the Indian population

Background: The superior gluteal artery (SGA) passes in between branches of the lumbosacral plexus after arising from the internal iliac artery. Variations in the course of SGA from the internal iliac artery till it passes out of the pelvis through the greater sciatic foramen are very important during pelvic surgeries. Pseudoaneurysm of SGA caused by iatrogenic injuries can compress branches of the lumbosacral plexus, causing foot drops and sciatica. Aims and Objectives: The aim is to study the course of the SGA in relation to branches of the lumbosacral plexus. Materials and Methods: A cross-sectional observational study was done on 25 formalin-fixed human adult cadavers. Dissections were performed in the pelvic region and branches of the internal iliac artery and lumbosacral plexus were identified. SGA was traced on both sides from origin till passing out of the greater sciatic foramen and its relation to branches of lumbosacral plexus was recorded. Results: Three types of pathways taken by SGA were identified in relation to the lumbosacral plexus. The most common path taken by the SGA was between the lumbosacral trunk (LST) and the first sacral nerve. Thirty-five out of 50 were of this type (70%). Ten out of 50 had the second most common type which was between L4 and L5 branches of LST (20%). Five cadavers had SGA lateral to LST (10%). Ten cadavers out of 25 (40%) had side differences in the type of course taken by SGA in relation to the lumbosacral plexus. Conclusion: A surgeon must keep in mind variations in the path taken by SGA in relation to the lumbosacral plexus to prevent pseudoaneurysms of SGA, which in turn can compress branches of lumbosacral plexus, causing foot drop and sciatica.

Endoscopic Endonasal Approach to the Orbit: A Case Series and Clinical Experience Emphasizing the Advantages of the Ipsilateral Mononostril Technique

BackgroundLesions situated within the orbit pose significant challenges in management due to the confined space they occupy and their proximity to critical anatomical structures. The objective of our study is to assess the feasibility of the ipsilateral endoscopic endonasal approach for orbital cavernous hemangiomas and to comprehend the surgical anatomy of the orbital apex and inferomedial orbital structures. MethodsThirteen patients with orbital cavernous hemangioma, who underwent surgery via the ipsilateral mononostril endoscopic endonasal approach between August 2018 and August 2023, were retrospectively evaluated. Demographic characteristics, clinical data, radiographic images, and clinical outcomes of the patients were collected from digital medical records. ResultsIn the study, we included 13 patients (8 female, 5 male) with ages ranging from 25 to 54 years (mean 35.2 ± 8.3). The left orbit was more commonly affected (9 left, 4 right). The average postoperative follow-up duration was 22.2 months (range 6 months – 50 months). Among the 13 cases of orbital cavernous hemangioma, 1 (7.7%) was located in the extraconal compartment, while 12 (92.3%) were situated in the intraconal compartment. Complete surgical resection of the tumor was successfully achieved in all patients. ConclusionsOur study highlights the potential advantages of employing a purely ipsilateral mononostril endoscopic endonasal approach for orbital surgery, particularly for accessing the orbital apex and managing medial and inferomedial orbital lesions. This technique holds promise for reducing morbidity and enhancing outcomes, especially when combined with careful patient selection, preoperative planning, and advanced endoscopic skills.

Consistent Reconstruction of Sacrococcygeal Pressure Ulcers using Modification of En Bloc Sliding Gluteus Maximus Myocutaneous Flap Technique

Background: The en bloc sliding gluteus maximus myocutaneous flap was introduced to preserve the vasculature, muscular integrity, sensory innervation, and normal gluteal contour with a midline scar in sacrococcygeal pressure ulcer reconstruction. However, its critical disadvantages include incomplete detachment of the origin of the gluteus maximus and central tension of the closed wound due to round ulcer excision. Therefore, we reviewed the surgical anatomy and applied modifications to achieve sufficient flap mobilization and to decrease complications.Methods: After fusiform or rocket-shaped ulcer excision, submuscular flap elevation was initiated by completely detaching the origin of the gluteus maximus, including the posterior iliac crest, followed by comprehensive lateral submuscular dissection in the gluteal space while preserving the neurovascular pedicles. Bony protrusions were tangentially resected from the lower sacrum and upper coccyx. After en bloc medial advancement of the bilateral flaps, defects were closed in layers, with muscle ligament fixation at the midline.Results: Twenty-nine patients underwent surgery for sacrococcygeal pressure ulcers (primary, n=22; recurrent, n=7). Transverse width of the excised ulcers was 5–12 cm (final defect, 7–15 cm). During the follow-up period (6 months to 7 years), no early postoperative complications or late aesthetic or functional discomfort occurred; however, intermittent skin sloughing occurred in four cases and one coccygeal sore recurrence occurred. The recurrent ulcer was treated using the same surgical method, with no recurrence after 2 years.Conclusion: This modification can be successfully used for the reconstruction of primary and recurrent sacrococcygeal pressure ulcers.

Intraoperative Videogrammetry and Photogrammetry for Photorealistic Neurosurgical 3-Dimensional Models Generated Using Operative Microscope: Technical Note.

Intraoperative orientation during microsurgery has a prolonged learning curve among neurosurgical residents. Three-dimensional (3D) understanding of anatomy can be facilitated with realistic 3D anatomic models created from photogrammetry, where a series of 2-dimensional images is converted into a 3D model. This study implements an algorithm that can create photorealistic intraoperative 3D models to exemplify important steps of the operation, operative corridors, and surgical perspectives. We implemented photograph-based and video-based scanning algorithms for uptakes using the operating room (OR) microscope, targeted for superficial structures, after surgical exposure, and deep operative corridors, in cranial microsurgery. The algorithm required between 30-45 photographs (superficial scanning), 45-65 photographs (deep scanning), or approximately 1 minute of video recording of the entire operative field to create a 3D model. A multicenter approach in 3 neurosurgical departments was applied to test reproducibility and refine the method. Twenty-five 3D models were created of some of the most common neurosurgical approaches-frontolateral, pterional, retrosigmoid, frontal, and temporal craniotomy. The 3D models present important steps of the surgical approaches and allow rotation, zooming, and panning of the model, enabling visualization from different surgical perspectives. The superficial and medium depth structures were consistently presented through the 3D models, whereas scanning of the deepest structures presented some technical challenges, which were gradually overcome with refinement of the image capturing process. Intraoperative photogrammetry is an accessible method to create 3D educational material to show complex anatomy and demonstrate concepts of intraoperative orientation. Detailed interactive 3D models, displaying stepwise surgical case-based anatomy, can be used to help understand details of the operative corridor. Further development includes refining or automatization of image acquisition intraoperatively and evaluation of other applications of the resulting 3D models in training and surgical planning.

[Multidimensional formats of surgical anatomy in otorhinolaryngology student teaching-acomparison of effectivity].

Technological change in healthcare and the digital transformation of teaching require innovations in student teaching in medicine. New technologies are needed to enable the delivery and use of diverse teaching and learning formats by educational institutions independent of time and place. The aim of this study is to analyze the effectiveness of different multidimensional formats in student teaching in surgical ENT medical anatomy. During the summer semester 2022 and winter semester 2022/2023, the digital teaching and learning program was expanded by testing different visualization formats (3D glasses, cardboards, or VR glasses) with students in the context of ahighly standardized surgical procedure, namely cochlear implantation. Apre- and post-intervention knowledge assessment was carried out in all groups, followed by an evaluation. Of 183 students, 91students fully participated in the study. The post-intervention knowledge assessment showed asignificant increase in correct answers regardless of visualization format. In adirect comparison, the operating room (OR) group answered correctly significantly more often than the cardboard group (p = 0.0424). The majority of students would like to see 3D teaching as an integral part of the teaching program (87.9%) and more streaming of live surgeries (93.4%). They see the use of the various technologies as avery good addition to conventional surgical teaching (72.5%), as good visualization (89%) increases retention (74.7%) and motivation (81.3%). Application and use of new visualization technologies in everyday clinical practice is apromising approach to expanding student training. Mobile, interactive, and personalized technical formats can be adapted to the learning behavior of students. Last but not least, the use of new media influences learning motivation. An expansion of digital teaching and learning formats can be expressly recommended on the basis of this study.

(265) The Surgical Anatomy of Clitoral Innervation: A Review of the Current Medical Literature

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. Fourteen papers discussed both somatic and autonomic innervation to the clitoris. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

Is identification and dissection of the external laryngeal nerve necessary during thyroidectomy? A prospective study

BackgroundCompared to the recurrent laryngeal nerve, the EBSLN (or external laryngeal nerve) is less studied in terms of its course and relationship with the thyroid gland. This is a prospective intraoperative study designed to identify the anatomical variations of the EBSLN in relation to the IPC, the superior thyroid pedicle, and the point where the nerve crosses the STA. Additionally, the study aims to propose a technical procedure for its preservation.MethodsWe conducted a prospective study of 50 patients (total of 100 nerves) undergoing total thyroidectomy at the Department of Surgery ‘B’ in Ibn Sina Hospital, Rabat. Intraoperatively, the EBSLN was visually identified and preserved before ligating the superior thyroid vessels. Each nerve was categorized using established classification systems.ResultsThe overall pooled EBSLN identification rate was 82%. Cernea type IIa (nerves crossing the STA less than 1 cm above the upper edge of the superior thyroid pole) and Friedman type II (nerves piercing the lower fibers of the IPC) were the most prevalent (64% and 44%, respectively). Kierner type IV (nerves crossing the branches of the STA immediately above the upper pole of the thyroid gland) was represented in 27% of cases.ConclusionA better understanding of surgical anatomy of the neck allows for better results of thyroidectomy by preserving the external and recurrent laryngeal nerves.

Endoscopic Endonasal Transcavernous Hemipituitary Transposition for Resection of Invasive Prolactinoma: 2-Dimensional Operative Video.

Invasive prolactinomas often require multimodal management including medical and surgical interventions. Here, we present the case of a 34-year-old man with a history of progressive visual disturbances. MRI unveiled a sella lesion with suprasellar and retrosellar extensions. Elevated prolactin levels (6125 ng/mL) confirmed the diagnosis of prolactinoma, leading to initiation of medical treatment, with gradual escalation to maximum dosing. The patient achieved only partial hormonal response and incomplete improvement of symptoms, and therefore, surgical intervention was pursued with objective of maximum safe resection. The patient consented to the procedure. An endonasal endoscopic approach was selected. Surgical procedures encompassed transsellar, transtuberculum, and transplanum approaches, extended laterally to expose the right parasellar carotid and the anterior wall of the cavernous sinus. Subsequent steps involved opening the sellar and suprasellar dura mater, anterior wall of the cavernous sinus, and transcavernous hemipituitary transposition for access to the retrosellar region.1-5 Debulking of the lesion was performed, followed by dissection of the retrosellar space and resection of tumor component within the interpeduncular cistern. Reconstruction employed dura substitute and vascularized nasoseptal flap. Histopathology confirmed diagnosis of prolactinoma. Postoperative MRI findings and significantly improved prolactin levels (50 ng/mL) were compatible with near total resection. The patient's postoperative course was uneventful, resulting in discharge on the second postoperative day. The patient was additionally started on cabergoline 0.5 mg 2x/week to achieve hormonal control. This case demonstrates the application of surgical anatomy and its translation in modern surgical techniques that allow improved resection of such complex tumors while ensuring optimal clinical outcomes.