Weight loss and cardiovascular outcomes with incretin-based therapies after metabolic and bariatric surgery: a nationwide US cohort study.

The superior labial artery mucosal (SLAM) flap is a versatile, pedicled axial flap ideally suited for mucosal lining in lower lip reconstruction. This article details the surgical anatomy and technique of the SLAM flap, highlighting its role as a standalone liner or mucosal adjunct to microvascular free tissue transfer in major composite reconstructions. Clinical success relies on preserving the submucosal venous plexus, with the axial blood supply from the superior labial artery providing resilience against prior radiation therapy. By providing pliable, homologous mucosa, the SLAM flap effectively restores oral competence and defines the vermilion border. The SLAM flap is a highly reliable option for internal lining in complex lower lip defects.

Microvascular decompression (MVD) for trigeminal neuralgia (TGN) typically entails mobilisation of the superior cerebellar artery or adjacent veins. Rarely, symptomatic compression arises from a tortuous vertebrobasilar system. These cases are challenging due to eloquence and distorted microsurgical anatomy in cerebellopontine angle (CPA) often needing more complex maneuvers like vessel transposition rather than conventional interposition technique. This technical note discusses MVD technical nuances for TGN from a tortuous vertebrobasilar system. Standard retrosigmoid craniotomy was carried out to access the CPA. Radioanatomical correlations within the CPA were analyzed and an exposure extending along the tortuous vertebrobasilar system was planned for surgical control and visualization. Cerebellomedullary and cerebellopontine cisterns were dissected using combination of sharp and blunt techniques to release cranial nerves and resolve neurovascular conflict. We demonstrate the resolution of neurovascular conflict from tortuous vertebrobasilar system using interposition technique, without needing large vessel transposition. We illustrate radioanatomical correlations within the CPA and demonstrate dissection techniques in this challenging subtype of MVDs. Our technical observations are generalizable to microneurosurgical cases.

Injury to the recurrent laryngeal nerve (RLN) remains a significant concern in thyroid surgery. The inferior thyroid artery (ITA) is frequently used as a landmark. Yet, the RLN-ITA relationship shows substantial anatomical variability, and the non-recurrent laryngeal nerve (NRLN) represents a rare but high-risk variant. This systematic review and meta-analysis quantified the prevalence of RLN-ITA topographic patterns and NRLN occurrence. A PRISMA-compliant search was performed across major databases up to May 1, 2025. Eligible studies included intraoperative, cadaveric, or mixed anatomical series reporting extractable numerical data on RLN-ITA relationships (anterior, posterior, interposed) and/or NRLN prevalence, using the hemisoma as the unit of analysis. Study quality was assessed with the AQUA tool. Proportions were pooled using Freeman-Tukey double arcsine transformation under a random-effects model with REML estimation. Heterogeneity was quantified with I², τ², and Cochran's Q, and prespecified subgroup analyses were conducted by study setting. Sixty studies (1973-2025) comprising 9,032 patients and 14,820 hemisomas were included. Fifty-seven studies contributed 14,169 hemisomas to the RLN-ITA synthesis. Crude proportions were posterior 54.43% (7,712/14,169), anterior 27.11% (3,841/14,169), and interposed 18.46% (2,616/14,169). Random-effects pooling confirmed a posterior course as the most frequent configuration (~ 52%, 95% CI ~ 46-58%), followed by anterior (~ 30%, 95% CI ~ 24-36%) and interposed (~ 18%, 95% CI ~ 15-21%), with very high heterogeneity (I² > 97%). Subgroup analyses of intraoperative (30 studies; 10,376 hemisomas) and cadaveric (25 studies; 3,589 hemisomas) series yielded similar distributions, with persistently high heterogeneity (I² > 94%). Across all studies, 39 NRLNs were identified, all on the right side, corresponding to a prevalence of 0.78% among right hemisomas (n = 4,974); no left-sided NRLNs were reported. The RLN most commonly courses posterior to the ITA, but anterior and interposed variants are sufficiently frequent to mandate systematic intraoperative verification before vessel ligation. The NRLN is rare and exclusively right-sided in available data, yet clinically significant due to its high injury risk. Marked between-study heterogeneity highlights the need for standardized definitions and side-specific reporting in future anatomical research.

The radial nerve is of particular importance in the spastic upper limb, as it innervates muscles that frequently exhibit spasticity as well as muscles that are often paretic. This study describes its anatomy at the elbow, to provide a surgical reference for selective neurectomy or nerve transfers in spasticity treatment. The radial nerve of sixteen fresh cadaveric upper limbs was dissected from the distal end of the radial groove to the point where the posterior interosseous nerve (PIN) runs within the supinator muscle. All branches were identified and documented. The branching order, based on the mean distance from the lateral epicondyle to the first branch innervating each muscle, was: brachialis, brachioradialis, extensor carpi radialis longus (ECRL), superficial branch, supinator muscle, extensor carpi radialis brevis (ECRB). A branch to the brachialis muscle originating from the radial nerve was present in 9 out of 16 specimens (56%). The brachioradialis muscle typically received two branches from the radial nerve, always arising proximal to the bifurcation into the superficial and deep branch and proximal to the ECRB branch. The ECRL was usually innervated by one or two branches, sharing a common origin with the brachioradialis or ECRB in over half of the specimens. The ECRB was innervated by a single branch, originating from the superficial branch in 7/16 cases (44%). Although the radial nerve at the elbow exhibits considerable variability, this study can provide an anatomical framework for surgical planning in selective neurectomy and nerve transfer procedures targeting the radial nerve.

The piriform aperture (PA) is a critical anatomical structure that forms the bony framework of the nasal inlet and influences nasal airway patency and support of the nasal base. This study aimed to present detailed morphometric and morphological data on the PA to contribute to the surgical anatomy of PA enlargement. Seventy adult crania (female, n = 34; male, n = 36) were included. Using standardized digital images, PA length, PA width, related craniometric distances, and planimetric area were measured with ImageJ software. PA morphology was classified into six types. PA length was 4.71 ± 0.67cm in females and 5.54 ± 0.50cm in males; PA width was 3.52 ± 0.39cm in females and 3.80 ± 0.35cm in males. PA area was 12.61 ± 2.77 cm2 in females and 15.99 ± 2.82 cm2 in males. PA length, width, width at the level of the infraorbital foramen, the nasion-anterior nasal spine distance, inter-infraorbital distance, rhinion-right/left infraorbital foramen distances, and PA area were significantly higher in males. Regarding morphological type distribution, the pear type was most frequent (42.86%), followed by inverted heart (21.43%), round (12.86%), teardrop (10%), and oval (8.6%). PA length in the round type was lower than in the pear/oval/teardrop types, whereas PA area in the oval type was higher than in the round type. PA morphometry demonstrates marked sexual dimorphism. In males, PA length was approximately 18% greater and PA area approximately 27% greater, reflecting the combined effect of increased length and width.

The success of a rhinoplasty procedure is dictated by a complete understanding of nasal surgical anatomy and keen patient assessment. Conscientious surgeons will create realistic expectations for patients based on the anatomy in front of them and their surgical expertise. The surgical consultation frames both patient and surgeon goals with the ultimate objective of creating a shared vision, which can be achieved in the operating room. Reproducible photography and excellent physical examination are key elements of rhinoplasty assessment. They enable the surgeon to focus on functional and aesthetic components of the nose and the rhinoplasty procedure. The nasal tip is complex and requires surgeons to analyze the dynamics, structure, and resultant implications of their surgical modifications. Considerations of the individual and their identity in society further promote the realization of preoperative goals for the nasal tip.

Inclusion cysts (ICs) are a recognized sequela of myeloschisis closure, particularly in patients who undergo in utero repair. These lesions and their management present a unique challenge in the context of tethered cord surgery. Early detection and appropriate surgical management are essential for reversing or preventing further neurological decline. We present the case of a 22-month-old girl who underwent fetal myeloschisis repair at 23 weeks' gestation. During routine screening, she was found to have progressive neurogenic bowel and bladder dysfunction, as well as stagnation in motor development. Imaging revealed a large lumbosacral IC, which was treated with maximal cyst resection. Surgical Technique: The accompanying illustrations and operative video highlight the microsurgical techniques used to resect the IC and detether the spinal cord. The cyst was dissected from the dura, opened along the midline, and debulked. Maximal resection of the cyst was then achieved by carefully removing the posterior and lateral elements of the cyst wall from the underlying spinal cord and nerve roots. This case highlights the importance of vigilant multidisciplinary surveillance, careful selection of surgical candidates, and the technical considerations involved in managing ICs in myelomeningocele patients.

Intraoperative nerve injuries during orthopaedic shoulder procedures can cause pain, paresthesia, and muscle weakness. Iatrogenic nerve injuries are often transient or subclinical, and it is believed that many neurologic injuries go undiagnosed. Several risk factors predispose patients to intraoperative nerve injury, including local tissue stiffness, revision surgery, low body mass index, medications, and decreased range of motion. Apart from patient-specific risk factors, there are direct and indirect mechanisms of injury related to surgical technique, including device implantation, nerve traction, patient positioning, retractor placement, and portal placement. Cadaveric, clinical, and intraoperative neuromonitoring studies have advanced our understanding of surgical anatomy and intraoperative mechanisms underlying nerve injuries during shoulder surgery. The primary purpose of this article is to review the neurologic complications during common open and arthroscopic shoulder procedures. This review will detail the neuroanatomic proximities around the shoulder, as well as provide recommendations from the literature on avoiding nerve injury.

Since the introduction of right hemicolectomy with complete mesocolic excision (CME) the implementation of minimally invasive CME as standard of care still remains challenging. Among several established guidelines for minimally invasive CME, the "critical view/open book" concept has been developed to provide a stepwise standardization with safety checkpoints for teaching purposes. The present study evaluates this concept during its practical application in a large series of surgical training courses. In this prospective observational study, seven consecutive 2-day surgical training courses based on the "critical view/open book" concept were offered to 125 attendees. Lectures on the rationale, surgical anatomy, techniques, and pitfalls of minimally invasive CME were followed by demonstration of predissected anatomical specimens. Tutored laparoscopic and robotic right hemicolectomies with CME were performed on body donors strictly adhering to the "critical view/open book" concept with subsequent quality assessment of resected specimens. A post-training questionnaire evaluated the "critical view/open book" concept related to its applicability, usefulness, efficacy, and adoption. The "critical view/open book" concept could be fully/mostly applied by 85.9% of the attendees during the surgical training courses. The most valuable insights gained were related to the retrocolic fascial system, vascular variations including the gastropancreaticocolic trunk, and the extent of mesocolic excision. Although most attendees had no previous experience with the "critical view/open book" concept, 83.3% of resected specimens fulfilled the highest quality standard (type 0, Benz classification). Intention to adopt the "critical view/open book" concept into clinical practice was stated by 80.9% of those attendees not previously familiar with this concept. The "critical view/open book" concept applied in surgical training courses proved to be an efficient teaching tool for minimally invasive CME and, thus, may be integrated into training curricula. Follow-up studies are needed to confirm its impact on long-term adoption and clinical outcome.

Rationale:Cystic duct (CD) variations are common biliary tract alterations; therefore, caution is required in the diagnosis and treatment of cholelithiasis in patients with gallbladder duct anomalies. Laparoscopic cholecystectomy (LC) is the preferred method for treating cholelithiasis or cholecystitis. Accurate preoperative imaging assessment, a thorough understanding of relevant surgical anatomy, and intraoperative precautions are required to effectively reduce the incidence of intraoperative bile duct injury.Patient concerns:We report the case of a 59-year-old male patient with common hepatic duct (CHD) stricture following LC. The patient’s CD entered the common bile duct from the left side and ran ventrally around the common bile duct. Postoperative examination revealed partial stenosis of the CHD caused by compression from an absorbable ligation clip and transient hyperbilirubinemia. Fortunately, prompt treatment prevented serious complications.Diagnoses:Cholelithiasis with cholecystitis and CD anatomical variation.Interventions:LC.Outcomes:Postoperative examination revealed partial stenosis of the CHD caused by compression from an absorbable ligation clip, with transient hyperbilirubinemia. The patient was discharged 3 days postoperatively and followed up for 10 months. The absorbable ligation clips were resorbed, and the CHD stenosis resolved.Lessons:Biliary tract surgeons must understand and master common variations of the CD and their clinical significance. Potential anatomical variations should be identified preoperatively, while the extrahepatic bile ducts should be carefully exposed intraoperatively. Whenever possible, absorbable ligation clips should be used to transect the CD while avoiding compression of the bile duct to prevent bile duct injury.

Large language models demonstrate increasing utility in healthcare; however, their capacity to handle newly developed medical content beyond training data boundaries remains unclear. This study evaluated the performance of four ChatGPT models on 120 newly developed questions from the 2024 Taiwan Urology Board Examination, all created after the models' October 2023 training cutoff, thereby reducing the risk of prior model exposure. Model performance was assessed using accuracy and processing time. Of 150 examination items, the first 120 newly developed questions constituted the primary analysis set; the remaining 30 previously used archival questions were excluded to reduce potential bias from prior exposure. The primary paired accuracy comparison evaluated o1-preview versus GPT-4o across all 120 questions. Additional analyses across 12 urological subspecialties and question-complexity strata were treated as exploratory. Across all 120 questions, o1-preview achieved 66.7% accuracy and significantly outperformed GPT-4o (55.8%; p = 0.012), although with longer processing time (19.20 vs. 14.94s). Performance varied significantly across 12 urological subspecialties (p < 0.001). Unlike the other tested models, o1-preview showed slightly higher accuracy on high-complexity than on low-complexity questions (68.3% vs. 65.0%). On high-complexity surgical anatomy items, o1-preview achieved 80.0% accuracy, whereas GPT-4o and GPT-4o mini both scored 0.0% (p = 0.024). On this newly developed post-cutoff, text-based urology board question set, o1-preview achieved higher overall accuracy than GPT-4o, particularly on high-complexity surgical anatomy items, at the cost of longer response times. These findings suggest that reasoning-oriented models may offer advantages for selected specialty-level assessment tasks, although generalizability to other languages, modalities, and clinical settings requires further validation.

Background: The glenohumeral ligaments are key stabilizers of the glenohumeral joint. Three distinct fascicles are usually described from the anterior surface of the shoulder joint: a superior glenohumeral ligament (SGHL); a middle glenohumeral ligament (MGHL); and an anteroinferior glenohumeral ligament (AIGHL). A remarkable interindividual variation has been reported, and there are few data about the patterns of insertion of these ligaments. A recent study provided a much-needed insight into the quantitative details of the glenohumeral ligament insertions. However, there is a lack of studies describing linear measurements (closer to real-life surgical anatomy) of glenohumeral ligamentous insertions according to their pattern. Methods: Hereby, we present a Thiel-based anatomical study describing proximal (glenoid) insertions of glenohumeral ligaments in 39 specimens from volunteer body donors to the Applied Anatomy Laboratory at the Autonomous University of Madrid. Results: Only 30.8% of cases showed a canonical pattern of SGHL, MGHL, and AIGHL, with scapular insertions ranging from 0.28 to 1.58 cm for SGHL, 0.1-3.6 cm for MGHL, and 0.45-2.05 cm for AIGHL, frequently mixed between the labrum and the osseous edge of the glenoid surface. Most cases show a single glenohumeral ligament inserted, usually in the labrum. A wide range of patterns regarding the number of insertions and their labral or osseous nature is present in our sample. Conclusions: Overall, there are three different patterns of glenohumeral ligaments in the anterior aspect of the shoulder joint, with the canonical pattern (three ligaments) represented in less than half of the cases. The morphometric study of the glenohumeral ligaments should consider their pattern of distribution. Also, insertions vary between the labrum and the scapular osseous articular surface.

Buccinator myomucosal flap for oral and oropharyngeal reconstruction: a series of 121 patients.

Call for candidates: co-Editor-in-Chief for Surgical and Radiologic Anatomy.

Background and ImportanceOptic nerve gliomas (ONGs) are benign and slow-growing tumors with a variable clinical course that may result in significant morbidity. The variability in tumor burden, challenging anatomy, and associated symptomatology require an individualized and multidisciplinary approach. The relative paucity of cases and variation in surgical anatomy prompt the need for accrual of cases in literature to advance the understanding of surgical techniques to address this rare clinical entity.Clinical PresentationA 19-year-old patient presented with severe and globe-threatening left eye proptosis, negatively affecting quality of life, due to a sporadic intraorbital ONG that had been inexorably growing over the previous 9 years, despite chemotherapy. The patient was taken to the operating room for a single-stage globe-sparing transorbital resection of the intraorbital ONG. The surgical plan consisted of an endoscopic endonasal approach for medial and inferior orbital wall decompression combined with an open lateral orbitotomy, via a lateral canthal incision, for subtotal piecemeal tumor resection to relieve the proptosis, restore alignment of the globe, and yield tissue for molecular analysis. The patient experienced profound improvement in quality of life and opted for radiographic surveillance that has been stable at 5 years.Discussion and ConclusionSurgical approaches to intraorbital tumors have included both transcranial and/or transorbital routes, with the latter more recently encompassing endoscopic endonasal techniques. This report presents the use of a novel combination of transorbital techniques for resection of an intraorbital ONG with severe proptosis, including an endoscopic endonasal approach combined with an open lateral orbitotomy.

Background A deep understanding of anatomy is essential for the professional education of competent clinicians, especially surgeons. This study explores an innovative format of live surgery on body donors complemented by interactive digital technologies and assesses its perceived educational value among students. By evaluating the individual digital technologies, this study also evaluates the format’s practical feasibility as a testing platform for digital technologies in surgical anatomy education. Methods Operations were performed on body donors by experts in a live format in front of an audience of 40–80 medical students. Surgeons and anatomy specialists interacted with students and explained procedures step by step. Students actively participated in the operations, gaining direct practical experience. In addition, the latest digital interactive technologies, such as virtual reality (VR) and augmented reality (AR), were continuously used and evaluated. Results Evaluations demonstrated that 96% of 412 participants were ‘very enthusiastic’ about the concept and appreciated the use of multimedia teaching methods. The Touch Surgery app was well received (mean 3.2 ± SD 1.3; Likert scale 1–5, where 5 indicated ‘fully applies’). By using interactive platforms such as Slido and TED, the contents could be repeated and prepared, which was highly appreciated (mean 4.4 ± SD 1.1; Likert scale 1–5, where 5 indicated ‘fully applies’). In particular, the use of computed tomography (CT) scans of the body donors was rated positively (mean 3.6 ± SD 1.4; Likert scale 1–5, where 5 indicated ‘fully applies’). Conclusions Live surgery using body donors improved not only the students’ self-reported anatomical knowledge but also the innovative digital technologies with a focus on VR and, in particular, the complementary use of CT datasets of body donors, were perceived positively. This new format is a valuable addition to the standard medical curriculum, providing students with further tools for a better understanding of surgical anatomy and potentially supporting greater confidence in long-term clinical practice.

Gubernacular discontinuity and abnormal distal fixation in cryptorchidism: Challenging the classical concept.

ObjectiveTo optimize incision placement for uniportal endoscopic lumbar fusion using computational methods to maximize disc and endplate preparation.MethodsWe analyzed 605 axial lumbar MRI images from 121 patients in an institutional development cohort and 120 MRI images from 40 patients in an independent external validation cohort. A parametric MRI-based anatomical delineation system was developed to define the relevant surgical anatomy, and genetic algorithm optimization was used to determine optimal incision placement. Machine learning was then used to predict optimal incision positions from MRI-derived anatomical features, including disc morphology, Kambin’s triangle width, dural sac width, and posterior longitudinal ligament-to-skin distance.ResultsGenetic algorithm optimization identified level-specific optimal incision distances: 58.93 ± 10.19 mm (L1-2), 63.31 ± 9.84 mm (L2-3), 67.79 ± 12.82 mm (L3-4), 83.89 ± 13.69 mm (L4-5), and 95.28 ± 19.38 mm (L5-S1). Under a patient-level framework, the artificial neural network (ANN) showed the best performance in predicting the GA-derived optimal incision position from MRI-derived anatomical features (internal validation R2 = 0.935; external validation R2 = 0.918 [95% CI, 0.869–0.947] and MAE = 6.08 mm [95% CI, 5.17–7.10]). The model was deployed online for real-time patient-specific planning.ConclusionA web-based computational planning tool was developed to optimize incision placement and maximize disc and endplate preparation in uniportal endoscopic lumbar fusion. This approach may support patient-specific preoperative planning.

Multimodal large language models (LLMs) are now deeply integrated into medical education and widely used by medical students, yet it remains unclear whether current models possess the accuracy and reliability needed to support image-based learning. We evaluated four state-of-the-art multimodal LLMs (ChatGPT-5.1, Gemini-2.5, Grok-4, Claude Sonnet-4.5) on 208 image-based examination questions from a Doctor of Medicine program, spanning anatomical pathology (histopathology; 47.6%), radiology (31.7%), and surgical anatomy (20.7%). To isolate visual reasoning, all items were presented in image-only form with contextual information removed. Items covered seven organ systems, included both constructed-response and selected-response formats, and were categorized as recognition-only or recognition-plus-reasoning. ChatGPT-5.1 achieved the highest accuracy (75.5%; 95% CI [69.2-80.8]), followed by Gemini-2.5 (59.6%; 95% CI [52.8-66.1]), Claude Sonnet-4.5 (41.8%; 95% CI [35.3-48.6]), and Grok-4 (34.6%; 95% CI [28.5-41.3]). Overall model performance differed significantly (p < 0.001; Cramér's V = 0.45). Pairwise McNemar comparisons showed significant differences between ChatGPT-5.1 and all other models (all p < 0.001; effect sizes 15.9-40.9 percentage points). Subgroup analyses demonstrated a consistent hierarchy (ChatGPT > Gemini > Claude ≈ Grok) across different categories. Accuracy was uniformly higher for recognition-only and selected-response items. Even the best-performing model, ChatGPT-5.1, answered approximately one in four questions incorrectly. These findings suggest that current multimodal LLMs cannot yet replace expert teaching in image-based learning. Their use in medical education should therefore remain supervised and critically appraised, serving as adjuncts rather than authoritative sources.