Surgical Implications Research Articles

A Case Report on Ellis–van Creveld Syndrome: Clinical, Embryological, Anesthetic, and Surgical Implications

AbstractPostaxial polydactyly (PAP) in the form of rudimentary soft tissue masses is quite common. Management involves ligation or surgical excision. Rarely do literature discussions cover complex variants in which the extra finger is fully developed. Ellis–van Creveld syndrome (EVC) or chondroectodermal dysplasia is a rare disorder characterized by PAP. When chondral dysplasia encompasses PAP, dwarfism, and genu valgum, ectodermal dysplasia involves nails and teeth. We describe two EVC cases. When one had cardiac malformations, the other had dental anomalies. One of them underwent genu valgum correction and removal of the additional finger. The hand surgery proved complex due to fusion of its metacarpal with the fifth metacarpal. Pediatric Outcomes Data Collection Instrument (PODCI) scores at 1.5 and 2.5 years after hand and knee surgeries were excellent. A multidisciplinary approach is essential to achieve comprehensive care. Additional embryological research is necessary to elucidate the clinical manifestations described in this report.

Exploring Nasal Wall Cartilage Asymmetry in Rhinoplasty: Implications for Postoperative Symmetry.

Facial symmetry is prized for its association with health, genetic quality, and attractiveness, but minor asymmetries are common. Human asymmetry tends to favor the left side and is noticeable in various nose parts. However, the discrepancy in cartilage thickness between the nose's right and left sides remains understudied. This cross-sectional study involved 60 patients undergoing primary open rhinoplasty. During routine rhinoplasty Procedure, upper and lower lateral cartilage strips were excised from each patient, yielding four tissue samples. Tissue thickness and width were measured using a microscope stage calibration slide. This approach systematically assessed left and right cartilage thickness differences in primary open rhinoplasty patients, offering insights into nasal asymmetry and potential surgical implications. Out of 60 patients, 43 were female (72%) and 17 were male (28%). The mean thickness of upper lateral (UL) cartilage was 0.53mm on the right and 0.54mm on the left side (P value= 0.52). For lower lateral (LL) cartilage, the mean thickness was 0.50mm on the right and 0.54mm on the left side (P value < 0.001), indicating significant left-sided dominance. This dominance was consistent across both sexes. Our study highlights the significance of addressing subtle nasal cartilage asymmetries to improve postoperative symmetry. Modifying nasal cartilage microstructures during rhinoplasty can enhance both aesthetic and functional outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical anatomy of the cystic artery: A systematic review with meta-analysis

BackgroundThe current evidence-based systematic review with meta-analysis presents a detailed overview of the cystic artery (CA) surgical anatomy, including its origin, number, topography, and morphometry. Moreover, the surgical implications of these variants are further discussed. MethodsAccording to the Evidence-Based Anatomy Workgroup and PRISMA 2020 guidelines, the systematic review was performed using four online databases. The Anatomical Quality Assurance Tool was used to evaluate the risk of bias. Meta-analysis was performed with the R programming software. The pooled prevalence and pooled mean of different CA parameters were calculated. ResultsThe CA most commonly originated from the right hepatic artery (a pooled prevalence of 85.75 %). Other described origins (in order of frequency) were the aberrant right hepatic artery, the common hepatic, the left hepatic, the gastroduodenal, the superior mesenteric, and the middle hepatic arteries. The CA was single in 88.59 %, while it can be identified as double, triple, or absent. Most commonly, it was located inside the cystohepatic triangle in 83.83 %. Most commonly, it was superomedially to the cystic duct (77.80 %) and posteriorly to the common hepatic duct (35.08 %). The CA pooled mean length was 21.34 mm, and its diameter was more commonly over 1 mm. ConclusionThe CA surgical anatomy is paramount when operating on the gallbladder. The CA's altered anatomy and adjacent area could lead to confusion, iatrogenic injury, and prolonged surgical time. The CA depicts high morphological variability; therefore, surgeons should consider the typical anatomy and possible (usual and unusual) variants.

Assessing the Feasibility of Selective Piezoelectric Osteotomy in Transorbital Approach to the Middle Cranial Fossa: Anatomical and Quantitative Study and Surgical Implications

ObjectivesTo verify the feasibility and to discuss advantages and disadvantages of a piezoelectric orbitotomy (PO) during Superior Eyelid Endoscopic Transorbital Approach (SETOA). MethodsFive adult specimens underwent exoscopic/endoscopic SETOA to middle cranial fossa. The surgical corridor was created via piezoelectric orbitotomy by performing three selective and safe micrometric bone cuts providing a one-piece trapezoid bone flap which was repositioned and secured at the end of procedure. A 3D scan of the bone flap allowed us to reconstruct a 3D model and calculate its volume. An illustrative case demonstrating the application of this novel technique was also presented. ResultsAnatomical-morphometric quantitative analysis showed a mean bony-volume gain of 1,574.26 mm3 by using PO.PO yielded concrete surgical advantages and theoretical benefits in terms of functional and esthetic outcomes. All osteotomies were micrometric clear-cut and precise, resulting in a very thin bony gap; a complete sparing of soft tissues and neurovascular structures in- and around the orbit was observed. Lateral orbital wall reconstruction by replacing the bone flap aims to mitigate the risk of enophthalmos, proptosis, CSF leakage, pseudomeningocele and pulsatile headache, which represent significant challenges in the relevant literature. ConclusionPO may offer a viable, selective, effective, safe alternative to high-speed drilling during SETOA, especially for patients affected by intra-axial pathologies in which a watertight closure is mandatory. This procedure could prevent/decrease the risk of some of the main postoperative complications associated to the standard SETOA, resulting potentially in better functional and esthetic outcome.

Biocompatibility and mechanical performance of magnesium alloys for biomedical application- a state of the art review

This review addresses the problems associated with various types of implants, providing a brief background on their challenges and surgical implications. Preclinical and clinical studies are discussed to understand the causes of implant failures. The review specifically examines the potential of magnesium-based alloys in biomedical applications, focus on existing research to offer a comprehensive overview of their advantages and disadvantages in biodegradable implants. It explores how alloying elements can enhance mechanical properties and corrosion behavior in Mg alloys. This review indicates how specific percentages of different alloying elements, combined with suitable manufacturing and post-processing techniques, can yield optimized results. Additionally, the review assesses the impact of magnesium alloy degradation on the healing process and suggests strategies to mitigate adverse effects. By thoroughly analyzing the literature, this paper offers valuable insights into fabricating magnesium-based implants to achieve ideal mechanical and corrosion properties, enhancing their effectiveness in biomedical applications.

Microsurgical Anatomy of the Common Tendinous Ring and Its Surgical Implications

BACKGROUND AND OBJECTIVES: The common tendinous ring (CTR), also known as the common annular tendon or annulus of Zinn, is a critical anatomic structure located at the convergence of the orbital apex, superior orbital fissure (SOF), optic canal, and the anterior aspect of the lateral sellar compartment. It plays a vital role in both neurosurgical and neuro-ophthalmological interventions. The aim of this study was to delineate the complex 3-dimensional (3D) topography of the CTR and explore its implications for surgical procedures. METHODS: Ten formalin-fixed skull base specimens from adult Chinese cadavers were meticulously dissected to investigate the morphology of the CTR, focusing particularly on its relationship with the 4 extraocular rectus tendons, the optic strut, the SOF, and the optic canal. Additional skull base specimens were subjected to 3D surface scanning, computed tomography, and histopathological examinations to deepen our understanding of the CTR's structural complexities. RESULTS: The CTR establishes a spatial, 3D tendinous assembly, encompassing 4 rectus tendons, 2 tendinous connections, and a singular common tendinous root. These components interlink to form a distinctive dual-ring configuration, featuring the optic foramen and the oculomotor foramen. The posterior part of the superior rectus tendon demarcates the common boundary between these 2 foramina. The oculomotor foramen itself serves as the central sector of the SOF. Precise incisions of the medial and lateral tendinous connections and fusions are essential for safely opening the CTR. CONCLUSION: The structural composition, interconnections, and dual-ring configuration of the CTR are crucial for precise and safe surgery of orbital apex and adjacent regions.

Anatomic variation of the vertebral artery: a case involving a persistent first intersegmental artery at C1-C2.

We observed a rare anatomical variation of a persistent first intersegmental vertebral artery in the C1-C2 region in an elderly Chinese male cadaver at Changzhi Medical College. In this case, the vertebral artery, rather than passing through the transverse foramen of the atlas, exits the transverse foramen of C2 and enters the spinal canal at the lower portion of the C1 posterior arch. The original transverse foramen of C1 was filled with connective tissue. This report details the anatomical characteristics of this abnormal vertebral artery and discusses its anatomical, surgical, and developmental implications. We describe the detailed morphological features of a rare VA variant and discuss the anatomical, clinical, and developmental aspects of this case. A case of head dissection. The anatomical characteristics of the VA were studied and documented, and anatomical measurements were collected. In this case, the vertebral artery, rather than passing through the transverse foramen of the atlas, exits the transverse foramen of C2 and enters the spinal canal at the lower portion of the C1 posterior arch. The original transverse foramen of C1 was filled with connective tissue. The anomalous development of segmental arteries in our case is linked to failures in the embryonic sclerotome reconstruction during development and failure.

Can Renal Masses Cross Midline? – Report of Three Cases of Renal and Visceral Midline Shifts Due to Abdominal Mass Effect

Abstract Primary retroperitoneal structures, particularly kidneys, are considered ‘fixed’ to the posterior abdominal wall by fasciae and vascular pedicles from the great vessels. However, huge masses arising in the retroperitoneum – either benign or malignant – are found to exert a mass effect in the retroperitoneal and intraperitoneal compartments, resulting in ‘visceral midline shift’. We present three different cases of retroperitoneal swellings causing extreme anatomical distortions in the abdomen and their surgical implications.

Comparison of the Vaginal and Labial Dimensions of Ethnic Chinese and Western Nullipara.

Vaginal dimensions have clinical and surgical implications. We sought to quantify the differences between vaginal and labial dimensions in healthy ethnic Chinese and Western women with normal pelvic organ support. This is a cross-sectional study of a convenience sample of ethnic Chinese nulliparas (n = 33) and Western nulliparas (n = 33) recruited for research purposes. For each subject, magnetic resonance imaging was used to quantify the vaginal and labial dimensions. Specifically, we identified the anterior and posterior vaginal wall, the outline of the cervix in the mid-sagittal and coronal planes, and the distance from the labia majora to the hymenal ring at the urethral meatus. There were significant differences in age and weight between groups. Substantial variation in vaginal and labial dimensions was found within each group. The vaginal and labial dimensions of ethnic Chinese women ranged from 9-21% smaller than those of Western women; In the ethnic Chinese group, increasing weight and BMI correlated with greater labial distance (r = 0.66 and r = 0.63 respectively); as did height and the distance from the vaginal opening to the cervical os (r = 0.5). In the Western group, only weight correlated with the labial distance (r = 0.51). Significant group differences in vaginal and labial dimensions were found, with the dimensions of Chinese nulliparas being up to 21% smaller than those of Western nulliparas.

State-Based Surgical Implications of Gunshot Wound Related Traumatic Injuries Stratified by Gun Law Strength

State-Based Surgical Implications of Gunshot Wound Related Traumatic Injuries Stratified by Gun Law Strength

A new classification for pterygomaxillary implants and its related surgical implications: a retrospective cohort study

BackgroundTo provide a novel classification for all implants in the maxillary retromolar region to simplify surgical design, reduce surgical risks, and guide clinicians in clinical decision-making.MethodsA total of 180 patients with bilateral partial or completely edentulous atrophic posterior maxillae who had received or were scheduled to receive pterygomaxillary implants were included in this study. Cone-beam computed tomography was performed, and the sagittal and coronal images were acquired at 110 kV and 10 mA. The exposure volume was 120 mm in diameter and 80 mm in height. The pterygomaxillary implants were divided into three different types based on the anatomical structures the implants passed through.ResultsThe average age of the 180 patients was 69 (range: 39–89) years; 99 were men and 81 were women. All the patients exhibited 360 pterygomaxillary implant sites. However, during mimic implantation, 14 implant sites were excluded due to severe resorption of the tuberosity, very small pterygoid plates, or variations in the descending palatal artery configuration. Of the 346 pterygomaxillary implant sites, 24.0% (83/346), 40.7% (141/346), 22.0% (76/346), and 13.3% (46/346) were classified as Types I, IIa, IIb, and III, respectively.ConclusionsType II pterygomaxillary implants were the most commonly used in the novel classification. Different types of pterygomaxillary implants should follow specific designs and surgical strategies to achieve optimal outcomes.

Posterior clinoid process in children: morphometric analysis, pneumatization ratio, and surgical implications.

To describe pneumatization and topographic position of the posterior clinoid process (PCP) in healthy children when approaching the anterior and middle fossae. The study consisted of computed tomography images of 180 pediatric patients (90 males / 90 females), aged 1-18years. The presence or absence of PCP pneumatization was noted, and the distances of certain landmarks to PCP were measured. The distances of the foramen ovale, foramen rotundum, superior orbital fissure, anterior clinoid process (ACP), foramen magnum and crista galli to PCP were measured as 18.59 ± 3.36mm, 15.37 ± 3.45mm, 14.60 ± 3.05mm, 5.27 ± 3.24mm, 32.03 ± 3.27mm, and 30.45 ± 3.93mm, respectively. These parameters increased with growth (between 1-18years), but the distance between PCP and ACP decreased with an irregular pattern. In 11 sides (3.10%), a fusion between PCP and ACP was determined. PCP pneumatization was identified in 32 sides (8.9%). Its pneumatization correlated with pediatric ages (p < 0.001), but not gender (p = 0.459) or side (p = 0.711). Most of PCP pneumatization appeared after late childhood period (i.e., between 10-18years). Our study provides beneficial data for neurosurgeons to use PCP as a reference point for creating a skull base map in children, because of the incomparable position of PCP in the skull base center.

Bringing Inclusivity to "Ethnic" Rhinoplasty: A Novel Anatomical Classification System.

"Ethnic rhinoplasty" is a term that historically has been employed to categorize patterns in nasal anatomy, possible procedures to change appearance, and patient and surgeon expectations for expected outcomes for the multitude of patients with features that belong to non-White groups. Categorizing anatomical structures based on broad definitions of race or ethnicity may not be an accurate representation, nor give an accurate depiction of nasal anatomical features. A shift is needed regarding how race and ethnicity are employed in describing nasal anatomy and rhinoplasty. We present a categorization system based on nasal anatomical patterns that may have more meaningful surgical implications without generalization into ethnic groups. Common anatomical nasal features such as projection, rotation, skin thickness, and anthropometric measurements were grouped into types, which may also help in patient education and remove any ethnic or racial terms.

The Anatomy of the Thoracic Duct and Cisterna Chyli: A Meta-Analysis with Surgical Implications.

Background: The thoracic duct (TD) and the cisterna chyli (CC) exhibit a high degree of variability in their topographical and morphometric properties. Materials and Methods: PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Google Scholar were searched to identify all studies that included information regarding the morphometric and topographical characteristics of the TD and CC. Results: The most frequent location of the TD termination was the left venous angle, with a pooled prevalence of 45.29% (95% CI: 25.51-65.81%). Moreover, the TD terminated most commonly as a single vessel (pooled prevalence = 78.41%; 95% CI: 70.91-85.09%). However, it divides into two or more terminating branches in approximately a quarter of the cases. The pooled prevalence of the CC was found to be 55.49% (95% CI: 26.79-82.53%). Conclusions: Our meta-analysis reveals significant variability in the anatomy of the TD and CC, particularly regarding TD termination patterns. Despite the predominance of single-vessel terminations, almost a quarter of cases exhibit branching, highlighting the complexity of the anatomy of the TD. These findings demonstrate the importance of detailed anatomical knowledge for surgeons to minimize the risk of accidental injury during head and neck, as well as thoracic surgeries. Our study provides essential insights that can enhance surgical safety and efficacy, ultimately improving patient outcomes.

Surgical Implications of GLP-1 Agonists for Weight Loss: Are These Patients Suitable for Elective Surgery?

Surgical Implications of GLP-1 Agonists for Weight Loss: Are These Patients Suitable for Elective Surgery?

Navigating the Intersection Between the Orbit and the Skull Base: The "Mirror" McCarty Keyhole During Transorbital Approach: An Anatomic Study With Surgical Implications.

McCarty keyhole (MCK) is the most important entry point during orbitocranial and cranio-orbital approaches; nevertheless, its anatomic coordinates have never been detailedly described from transorbital perspective. To provide the spatial coordinates for intraorbital projection of the "mirror" MCK by using the well-established main anatomic-surgical bony landmarks met along transorbital corridor. MCK was identified in 15 adult dry skulls (30 sides) on exocranial surface of pterional region based on the well-defined external bony landmarks: on the frontosphenoid suture, 5 to 6 mm behind the joining point (JP) of frontozygomatic suture (FZS), frontosphenoid suture (FSS), and sphenozygomatic suture (SZS). A 1-mm burr hole was performed and progressively enlarged to identify the intracranial and intraorbital compartments. Exit site of the intraorbital part of burr hole was referenced to the FZS on the orbital rim, the superior orbital fissure, and the inferior orbital fissure and to the JP of FZS, FSS, and SZS. To electronically validate the results, 3-dimensional photorealistic and interactive models were reconstructed with photogrammetry. Finally, for a further validation, McCarty mirror keyhole was also exposed, based on results achieved, through endoscopic transorbital approach in 10 head specimens (20 sides). Intraorbital projection of MCK was identified on the FSS on intraorbital surface, 1.5 ± 0.5 mm posterior to JP, 11.5 ± 1.1 mm posterior to the FZS on orbital rim following the suture, 13.0 ± 1.2 mm from most anterior end of superior orbital fissure, 15.5 ± 1.4 mm from the most anterior end of the inferior orbital fissure in vertical line, on measurements under direct macroscopic visualization (mean ± SD). These values were electronically confirmed on the photogrammetric models with mean difference within 1 mm. To be aware of exact position of intraorbital projection of MCK during an early stage of transorbital approaches provides several surgical, clinical, and aesthetic advantages.

Cholangiocarcinoma of the Middle Bile Duct: A Narrative Review.

Resectable cholangiocarcinoma (CCA) arising from the middle of the extrahepatic biliary tree has historically been classified as perihilar or distal CCA, depending on the operation contemplated or performed, namely the associated hepatectomy or pancreaticoduodenectomy, respectively. Segmental bile duct resection is a less invasive alternative for select patients harboring true middle extrahepatic CCA (MCC). A small, yet growing body of literature has emerged detailing institutional experiences with bile duct resection versus pancreaticoduodenectomy or concomitant hepatectomy for MCC. Herein, we provide a brief overview of the epidemiology, preoperative evaluation, and emerging systemic therapies for MCC, and narratively review the existing work comparing segmental resection with pancreaticoduodenectomy or less commonly, hepatectomy, for MCC, with emphasis on the surgical management and oncologic implications of the approach used.

Classification of variant portal vein anatomy based on three-dimensional CT: surgical implications

PurposesThe purpose of this study was to develop a new and more comprehensive classification system for portal vein (PV) variations using three-dimensional visualization and evaluation (3DVE) and to discuss the prevalence rates and clinical implications of the variants.MethodsThe anatomies of PVs were tracked and analyzed by using three-dimensional visualization of CT images acquired between 2013 and 2022. Scans from 200 adults were evaluated and a total of 178 patients (N = 178) were included in the study. The new classification system, named BLB classification, was developed based on the level of the absent PV branch in each variant anatomy.ResultsUsing the BLB classification system, PVs were divided into thirteen subtypes. Only 82.6–84.8% of the portal veins of the 178 patients were depicted in Atri’s, Cheng’s or Covey’s classification, compared with 100% identified by the BLB classification. The BLB classification was validated against external data sets from previous studies, with 97.0-98.9% of patients classified by the BLB system.ConclusionVariant PV anatomies are more commonly seen based on 3DVE than in previous reports. The BLB classification covers almost all portal vein variants and may be used for planning liver surgery.

Positional Variations and Surgical Implications of Bony Overhangs in the External Auditory Canal

Abstract Background: This study examines the anatomical differences in the external auditory canal (EAC), particularly bony overhangs that hinder middle ear access, affecting diagnosis and surgical procedures. It seeks to categorize these overhangs for better surgical planning, offering a classification system essential for otologists and middle ear surgeons aiming at improved surgical outcomes. Materials and Methods: This retrospective analysis at a tertiary care hospital reviewed patient records and surgical videos from November 2017, focusing on otological procedures. Excluding individuals with EAC erosions or previous surgeries, it recorded demographics, diagnoses, and details of surgeries, including bony overhang locations. The study employed descriptive statistics, Chi-squared tests, and predictive analysis to explore the impact of bony overhangs on surgical requirements. Results: This study analyzed 333 ears from 305 patients undergoing middle ear and mastoid surgeries, finding a significant association between EAC types and bony overhang distribution, confirmed by a Chi-square test (P value ≈ 1.63 × 10 −83). Despite a predominance of female patients (59%), no significant correlation was observed between EAC types and patient age or gender. However, disease duration showed a significant relationship with EAC types, with predictive analysis indicating a high likelihood of requiring canalplasty for specific EAC configurations. Conclusion: Our research presents a clinical classification for EAC and tympanic annulus overhangs, underscoring their role in surgical visibility and middle ear operation challenges. It corroborates earlier studies, stressing the need to grasp EAC variations for improved surgical planning, overcoming obstacles, and enhancing middle ear surgery outcomes, thus refining surgical methods for patients with such anatomical differences.

Incomplete Transverse Pulmonary Fissures: Embryological Basis, Clinical, and Surgical Implications: A Cadaveric Case Report

Incomplete pulmonary fissures (IPF) represent a common anatomical variation in the human lung. While often considered silent, incomplete pulmonary fissures can have notable clinical and surgical implications, necessitating a comprehensive understanding of their anatomical characteristics. IPF may have significant implications in both clinical practice and surgical interventions. We report a case of an incomplete transverse fissure of the right lung from an adult male cadaver, exploring the embryological basis, clinical significance, and surgical implications. The findings underscore the importance of understanding the lung embryology and resulting normal anatomy, and associated anatomical variations to ensure accurate diagnosis, appropriate management, and optimal surgical outcomes.