Surgical Implications Research Articles

Critical carotid artery stenosis involving a persistent primitive hypoglossal artery

Persistent primitive hypoglossal artery (PPHA) is a rare internal carotid-vertebrobasilar anatomic variant. Awareness of this anomaly and its propensity for atherosclerotic disease is important to avoid misinterpretation of diagnostic studies and to allow appropriate interventional planning. As the predominant vascular supply to the anterior and posterior cerebral circulation, its luminal compromise can lead to devastating ischemic complications. Carotid endarterectomy and carotid stenting have both been performed to treat lesions involving a PPHA. Herein, we report a case of carotid endarterectomy involving a PPHA and discuss the clinical and surgical implications of a carotid lesion in the presence of a PPHA.

Robotic versus Laparoscopic Cholecystectomy: Case-Control Outcome Analysis and Surgical Resident Training Implications.

BackgroundThe robotic approach in surgery is becoming more widely used in many subspecialties. Robot-assisted laparoscopic procedures provide potential improvements in clinical outcomes due to improved visualization and enhanced surgical ergonomics. In this study, we measured and compared outcomes of robot-assisted laparoscopic cholecystectomy with the conventional laparoscopic technique, as well as the implications for the training of surgical residents.MethodWe compared a total of 244 patients undergoing minimally invasive cholecystectomies performed by one surgeon between July 2013 and June 2016 examining relevant clinical outcomes including operative room (OR) time, length of hospital stay (LOS), readmission to the hospital, post-operative emergency department (ED) visits, and post-operative pain between laparoscopic single-incision cholecystectomy and robot-assisted laparoscopic cholecystectomy. A chi-square test and Student’s t-test were used to compare these variables between the two groups. Propensity score matching (PSM) was used using gender, age, and body mass index (BMI) as variables.ResultsFrom the total number of procedures of 244, 144 were included in the laparoscopic group and 100 in the robot-assisted group. The robot-assisted patients had a shorter post-operative LOS (mean: 0.8 vs. 1.6 days; p = 0.002). There was no significant difference in the OR time (mean: 64.8 vs. 65.0 minutes; p = 0.945), readmissions (4.0% vs. 3.5%; p = 0.830), post-operative ED visits (7.0% vs. 7.6%; p = 0.851), or post-operative pain (13.0% vs. 21.3%; p= 0.137). Robotic cholecystectomy patients were younger (mean: 46 vs. 52 years; p = 0.023) and had lower BMIs (mean: 31 vs. 33; p = 0.038). Because of these differences, we compared the two groups using PSM that confirmed the shorter LOS in the robotic group (mean: 0.9 vs. 1.9; p = 0.009).ConclusionsThese results demonstrate that robotic cholecystectomies can reduce LOS for patients undergoing laparoscopic cholecystectomy, without increasing OR time. Increased surgeon experience with robotic procedures and improved OR efficiency will allow greater opportunities for resident participation. Robotic training curricula need to be employed and objectively evaluated to improve surgical resident skill acquisition and provide earlier and progressive clinical participation in robotic procedures.

More Than Just Cerumen: Lesions of the External Auditory Canal and Their Surgical Implications

There is an extensive differential diagnosis for lesions of the external auditory canal, including congenital, benign, locally aggressive, and malignant processes. Although external auditory canal lesions are commonly identified clinically, imaging is helpful to determine if the process is isolated to the external auditory canal or to evaluate the extent of involvement of adjacent structures. Because staging of external auditory canal malignancy is based on the location and extent of tumor rather than the cell type, multimodality imaging is often necessary for surgical planning. This article reviews defining clinical and imaging features of external auditory canal lesions, presents an organized approach to their characterization on CT and MR imaging, and discusses their surgical implications.Learning Objective: To review the differential diagnosis of external auditory canal lesions and recognize their key imaging and clinical features, including surgical implications.

Ansa cervicalis and hypoglossal nerve topographical relation: anatomical study on cadavers.

Ansa cervicalis and hypoglossal nerve are important neural structures of the neck. Their topographical disposition have important clinical and surgical implications. As described in a recent consensus, the ansa cervicalis originates in the spinal cord and then joins the hypoglossal awhile, without exchanging fibers, diverging from it to innervate the infrahyoid muscles. However, some dissection studies show individuals in which ansa cervicalis and hypoglossal nerve follow independent trajectories, diverging of classical characterization. This anatomical variation supports the need for better description of the link between these nerves and, therefore, improve surgical planning and technique. This project objective is to better characterize the relationship between ansa cervicalis and hypoglossal nerve, describing the percentage of link between these structures. In this regard, it will be realized a cross‐sectional study with 15 cadavers bilateral neck dissections. The study plans to analyze the data through nonparametric statistics. Our analysis will assess correlations between the topographic variety and sex, age, ethical and anthropometric characters of individuals. So far, we dissected 5 cadavers; of these 4 (80%) have ansa cervicalis not connected to hypoglossal nerve, meanwhile just 1 (20%) have this link. The project schedule predicts 10 more corpses dissections until January 2020. Until now, the small sample limit statistical analysis, but certainly it suggests there is a significant anatomical variant in the brazilian population. It is expected that our final results will contribute to better comprehension of these important neck structures and improve medical practice.

Case Report: An Atypical Innervation to the Gluteus Maximus by the Sciatic Nerve and its Clinical Implications

Anatomical variations, concerning the gluteus maximus (GM), are uncommon and of clinical importance. Usually, the GM is innervated by Inferior Gluteal Nerve (IGN), a branch of the sacral plexus arising from the ventral rami of L5 to S2. An unusual innervation was identified in routine cadaveric dissection in an elderly Puerto Rican female. Here, both the left and right GM were innervated by their corresponding IGN, yet both had an additional innervation by the Sciatic Nerve (SN). The bilateral SN branch to the GM was located proximally, when compared to the IGN, and emerged by the inferior border of the Piriformis muscle. In literature, there have been previous studies reporting multiple forms of innervations to the GM by the SN. Nevertheless, in these cases, the IGN was absent, and this anomaly was usually unilateral.The implications of this variation encompass both clinical and surgical correlations with respect to patient care. Regarding clinical aspects, patients with this dual variation to the GM can present with unique clinical scenarios which might be easily misdiagnosed. For instance, pain caused by inflammation of the GM in these patients might be misinterpreted and associated to pain felt in other conditions related to the SN, such as sciatica and piriformis syndrome. Likewise, women considering surgical intervention in this area might be at a higher risk of an iatrogenic nerve injury due to the anomalous SN branch to the GM.Thus, goal of this case report is to highlight the clinical and surgical implications of this finding based on the variant anatomy of the gluteal region. Physicians need to be aware of the existence of this variation. This might clarify the puzzling clinical manifestations of patients with the latter as well as avoid iatrogenic nerve injuries during surgical interventions.

Brain capillary telangiectasias: from normal variants to disease.

Brain capillary telangiectasias (BCTs) are small, dilated capillary networks in the brain that are most commonly asymptomatic. Though rare, symptomatic cases of BCTs have been reported, and it is therefore important to understand the nature of these lesions in order to facilitate proper recognition. Relative to other intracranial vascular malformations, updated information on the various epidemiologic, radiographic, and pathologic features of BCTs within the published literature may be inadequate. We searched the PubMed database for prior reports of symptomatically-manifested BCTs. Moreover, Google Scholar and PubMed were searched in order to review current epidemiologic, radiographic, pathologic, and pathogenetic features of BCTs. Forty-eight published studies were included for a total of 99 individual cases of BCTs with symptomatic manifestations. Thirty-three symptomatic BCTs were hemorrhagic in nature, while 66 were non-hemorrhagic. The mean age at presentation of hemorrhagic lesions was 25.5years, and the most common location was the supratentorial CNS (54.5%) with motor disturbance representing the most commonly encountered presenting symptom (26.1%). 15.2% of hemorrhagic lesions were treated with surgical removal. In non-hemorrhagic lesions, the mean age at presentation was 39.8years with the pons being the most common lesion location (78.5%) and headache being the most common presenting symptom (22.2%). 12.1% of patients with non-hemorrhagic lesions were treated with surgical removal. Despite their rarity, symptomatic BCTs, both hemorrhagic and non-hemorrhagic, can cause devastating neurological sequelae, potentially through multiple mechanisms. The large majority of these lesions do not require intervention, though surgical removal has been achieved with good outcome in select cases. Further documentation of symptomatic manifestations with or without surgical intervention is vital in order to further understand the clinical, surgical, and pathogenic implications of these less-appreciated vascular malformations.

Pediatric medulloblastoma in the molecular era: what are the surgical implications?

Pediatric brain tumors are the leading cause of childhood cancer mortality with medulloblastoma (MB) representing the most frequent malignant tumor. Although standardization of therapy resulted in a 2-fold reduction in mortality in patients with MB by 2002, it became clear that further improvements in clinical outcome would require a deeper understanding of the biology of MB. Employing the four main molecular MB subgroups (Wnt, Shh, Group 3 and Group 4), a restratification into clinicogenomic risk categories quantified an unacceptable survival for the high-risk group, urging researchers to focus their efforts towards acquiring a greater biological understanding of these children. Advancing in parallel with the molecular characterization and understanding of pediatric MB is the clinicogenomic correlations giving rise to recommendations for neurosurgical care. While unique observations that distinct radiological patterns can be identified to inform the MB molecular subgroup preoperatively, current neurosurgical practice remains maximal safe surgical resection followed by risk-adapted provision of adjuvant therapy in the context of a clinical trial.

Trauma on the high seas: an overview of recreational water use injuries

Recreational water use (RWU) injuries span from superficial lacerations to even death. Given the global popularity of RWU, radiologists should be aware of the common mechanisms and key imaging findings related to injuries in this setting. The goal of this article is to depict common RWU injuries and their emergent radiographic findings, which may have both important surgical and management implications. We present a broad review with case illustrations of these injuries seen at our level 1 trauma center showing the breadth of injury that can occur, general mechanisms and sample imaging findings.

Surgical implications of recent modalities for parathyroid imaging.

Clinical or subclinical primary hyperparathyroidism (PHPT) is one of the most common endocrine disorders in the world. Parathyroidectomy is the treatment of choice in symptomatic patients, stabilizing the progression of complications caused by the destruction activity of parathyroid hormone (PTH). Parathyroid surgical techniques have evolved over the years from bilateral neck exploration, to minimally invasive single parathyroid gland exploration, to minimally invasive video-assisted parathyroidectomy. Localization of the abnormal parathyroid gland before surgery is crucial for the operation to be effective. Increased incidences of reoperations of the parathyroid glands and the rapid development of minimally invasive methods led to the development of new localization techniques. The noninvasive studies include ultrasound (US), computed tomography (CT), magnetic resonance (MR) and 99mTc-methoxyisobutylisonitrile (MIBI) scintigraphy combined with single-photon emission CT (SPECT/CT). Among the latest technologies, the four-dimensional (4D)-CT scan, positron emission tomography (PET)/CT and PET/MR are very promising, and are going to have surgical implications in the future.

1.5 T magnetic resonance imaging generates accurate 3D proximal femoral models: Surgical planning implications for femoroacetabular impingement.

The objective of this study was to validate three-dimensional (3D) proximal femoral surface models generated from a 1.5 T magnetic resonance imaging (MRI) by comparing these 3D models to those derived from the clinical "gold standard" of computed tomography (CT) scan and to ground-truth surface models obtained by laser scans (LSs) of the excised femurs. Four intact bilateral cadaveric pelvis specimens underwent CT and MRI scans and 3D surface models were generated. Six femurs were extracted from these specimens, and the overlying soft tissues were removed. The extracted femurs were then laser scanned to produce a ground-truth surface model. A 3D-3D registration method was used to compare the signed and absolute surface-to-surface distances between the 3D models. Absolute agreement was evaluated using a 95% confidence interval (CI) derived from the precision of the LS ground-truth. Paired samples t tests and Kolmogrov-Smirnov tests were performed to compare the differences between the signed and absolute surface-to-surface distances between the models. The average signed surface-to-surface distances for the MRI vs LS and MRI vs CT models were 0.07 and 0.16 mm, respectively. These differences fell within the 95% CI of ±0.20 mm indicating absolute agreement between the surface models generated from these modalities. The signed surface-to-surface distance was significantly smaller for MRI vs LS ground truth model as compared with the CT vs LS model. Femoral models derived from a 1.5 T MRI scan demonstrated absolute agreement with the clinical gold standard of CT-derived models and were most like LS ground truth models of the excised femurs.

The Neural Sulcus of the Cervical Vertebrae: A Review of Its Anatomy and Surgical Perspectives.

The neural sulcus is a bony channel that spans the transverse process in the subaxial cervical spine. It is located between the anterior and posterior tubercles on either side of the transverse foramen, housing the spinal nerve as it passes through the intervertebral foramina. Although numerous studies have evaluated the anatomy of the cervical spine, very little data on detailed anatomy of the neural sulcus and its implication in cervical spine surgery exist. Here, we review the anatomy of the neural sulcus and surgical considerations. The neural sulcus has important surgical implications, and knowledge of its anatomy is important in considering and planning posterior cervical segmented instrumentation. This increases the ability of the neurosurgeon to choose the best suitable surgical approach to the subaxial cervical spine, allowing good outcomes for the patient.

Proposal of the 3O (Obstruction, Ureteric Orifice, and Outcome) Subclassification System Associated with Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA).

To propose a "3O" (obstruction, ureteric orifice, and outcome) subclassification system associated with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). Retrospective case series. Xiangya Hospital, Central South University, Changsha, Hunan, China. A total of 26 women with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) over a 9-year period. Not applicable. In all cases, the obstruction, ureteric orifice, outcome and surgical strategy were reviewed. In our study, the "obstruction" category included 14 cases of blind hemivagina, 8 cases of buttonhole septum, 3 cases of cervical fistula, and 1 case of cervical atresia. A total of 25 patients with vaginal obstruction underwent resection of the vaginal septum. The patient with cervical atresia underwent a failed cervicoplasty, followed by hemi-hysterectomy. The "ureteric orifice" category included 24 cases of absent ureter with no orifice, as well as 2 cases of ureteric orifice emptying into the obstructed hemivagina. The 2 patients were treated with laparoscopic extirpation of the ectopic ureter and renal moiety. Regarding the "outcome" category, 5 patients with severe recurrent hematometra, hematosalpinx, and ovarian endometrioma underwent hemi-hysterectomy, salpingectomy, and cystectomy of the ovarian endometrioma. Both patients (1 with a septate uterus and 1 with a bicornuate uterus) who experienced recurrent abortion accepted uterine correction. We provide new insights into the anatomical variants of this rare syndrome with the relevant surgical implications. Magnetic resonance imaging is the most useful tool in 3O diagnosis.

Surgical and oncological implications of aberrant arterial anatomy in patients undergoing pancreatoduodenectomy.

Whipple's pancreatoduodenectomy is a complex surgical procedure and any aberrant arterial anatomy may have serious surgical implications. The objective of our study was to analyse the frequency of aberrant hepatic artery and compare the outcomes in patients with normal anatomy. Clinical data and computed tomography scans of 45 consecutive patients who underwent Whipple's procedure from 2007 to 2016 were reviewed. Group 'A' included patients with aberrant hepatic artery while group 'B' with normal anatomy. Aberrant hepatic artery was present in 11 (24%) patients and type V was the most common variant (n=5, 45%). Morbidity rate in group A was 82% and group B was 62% (p= 0.288), while 30-day mortality rate was 18% and 9% respectively (p=0.582). There was no difference in the oncological clearance in both the groups. Aberrant hepatic artery does not seem to influence the morbidity, mortality and tumour resection margins in patients undergoing Whipple's procedure.

ANATOMICAL VARIATIONS OF THE SUPERIOR MESENTERIC ARTERY AND ITS CLINICAL AND SURGICAL IMPLICATIONS IN HUMANS.

ABSTRACT Introduction: Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical variations in this vessel contribute to problems in the formation and/or absorption of this part of the intestine and its absence has been recognized as the cause of congenital duodenojejunal atresia. Objective: To analyze SMA anatomical variations in humans and the possible associated clinical and surgical implications. Methods: This is a systematic review of papers indexed in PubMed, SciELO, Springerlink, Science Direct, Lilacs, and Latindex databases. The search was performed by two independent reviewers between September and December 2018. Original studies involving SMA variations in humans were included. SMA presence/absence, level, place of origin and its terminal branches were considered. Results: At the end of the search, 18 studies were selected, characterized as for the sample, method to evaluate the anatomical structure and main results. The most common type of variation was when SMA originated from the right hepatic artery (6.13%). Two studies (11.11%) evidenced the inferior mesenteric artery originating from the SMA, whereas other two (11.11%) found the SMA sharing the same origin of the celiac trunk. Conclusion: SMA variations are not uncommon findings and their reports evidenced through the scientific literature demonstrate a great role for the development of important clinical conditions, making knowledge about this subject relevant to surgeons and professionals working in this area.

Imaging anatomy of the retrotympanum: variants and their surgical implications.

The retrotympanic anatomy is complex and variable but has received little attention in the radiological literature. With advances in CT technology and the application of cone beam CT to temporal bone imaging, there is now a detailed depiction of the retrotympanic bony structures.With the increasing use of endoscopes in middle ear surgery, it is important for the radiologist to appreciate the nomenclature of the retrotympanic compartments in order to aid communication with the surgeon. For instance, in the context of cholesteatoma, clear imaging descriptions of retrotympanic variability and pathological involvement are valuable in pre-operative planning.The endoscopic anatomy has recently been described and the variants classified. The retrotympanum is divided into medial and lateral compartments with multiple described potential sinuses separated by bony crests.This pictorial review will describe the complex anatomy and variants of the retrotympanum. We will describe optimum reformatting techniques to demonstrate the structures of the retrotympanum and illustrate the associated anatomical landmarks and variants with CT. The implications of anatomical variants with regards to otologic surgery will be discussed.

Prevalence and implications of thyroid related embryological remnants: A prospective study of 1118 total thyroidectomies.

Context:Modern thyroid surgery has undergone a paradigm shift from subtotal thyroidectomy to an extended total thyroidectomy (TT) even for benign disorders. This entails removal of all embryological remnants even in benign disorders.Aims:To study the prevalence of various embryological remnants of the thyroid and surgical utility and implications in preventing complications.Settings and Design:Retrospective study of total thyroidectomies done by a single endocrine surgeon by standardized technique.Methods and Material:A detailed search of all embryological rests including Pyramidal tract (PT), Tubercle of Zuckerkandl (TZ), and Thyro-thymic thyroid rests (TTR) were done in 1118 patients undergoing TT over 6 years. The cases with and without TTR were divided as Group A and B, respectively. Their prevalence and impact on parathyroid preservation and other clinical parameters were analysed.Statistical Analysis Used:Descriptive analyses.Results:Out of the 1118 TT cases, TTR was seen in 230 (20.57%) cases, TZ in 598 (53.48%), cases and PT in 641 (57.33%) cases. Among group-A (n = 230), 213 had unilateral and 17 had bilateral TTR with 51 (22.17%) having retrosternal extension. Compressive symptoms, presence of TZ and PT were also significantly higher in group A. On follow up the incidence of temporary hypoparathyroidism was significantly higher in group-A, where as permanent hypoparathyroidism, temporary and permanent vocal cord palsy were comparable between the two study groups.Conclusions:Embryological remnants related to thyroid are not uncommonly encountered during total thyroidectomy. A thorough search and complete removal is crucial for the successful outcome of the procedure.

A rare case of internal carotid artery trifurcation and an aneurysm associated with it

Existing literature is devoid of data on true trifurcations of the internal carotid artery (ICA). The authors present a rare case of trifurcation of the ICA, discovered during the evaluation of a patient with subarachnoid haemorrhage, and discuss the surgical implications of the anomaly.

A Comprehensive Review of the Anatomy of Popliteus and Its Clinico-Surgical Relevance

An extensive anatomical knowledge of the muscle popliteus and its tendon is indispensable to understand the posterolateral structures of the knee which is prone to injury compared to the medial knee structures. This study describes all the relevant anatomical details of the muscle and its clinical significance. Anatomical and clinical terms regarding the popliteus muscle are searched using databases and search engines for the collection of literature review. Abstracts and articles describing the posterolateral corner (PLC) structures apart from the muscle studied were excluded. Seventy-six articles were adopted using the inclusion and exclusion criteria, among which 62 articles had fulfilled the need. Original articles dealing with morphology and morphometric analysis of popliteus muscle are scarce. Hence, the finer details of the anatomy of the muscle in various populations are unavailable, which is considered as a deficiency of the study. This article deals with the morphology of the popliteus and its clinical and surgical implications pertaining to the PLC of the knee.

Axillary artery variation: The rule not the exception

Introduction: Anatomic morphology commonly depicted in atlases or textbooks is often emphasized in gross anatomy classrooms; however, considerable variation may be observed in cadavers during dissection, particularly in the vascular system. This study statistically assesses the frequency of the classic versus variant axillary artery branching pattern and compares these observations to the incidence of variation described in the literature. Material and Methods: Axillary artery branching pattern was studied in 62 cadaver limbs. A Chi square goodness of fit test with post hoc analyses on the adjusted standardized residuals was used to evaluate branching patterns. Results: A statistically significant difference existed between the observed and expected frequencies of the classic presentation (P < 0.001). The axillary artery branching pattern exhibited the classic presentation in 17.7% of this sample; 82.3% of the limbs displayed a variant in at least one major axillary artery branch. The lateral thoracic and posterior circumflex humeral arteries were significantly variable branches observed in their textbook locations in 40.3% and 61.3% of cases, respectively. The superior thoracic, thoracoacromial, and subscapular arteries were significantly conserved branches documented in their textbook locations in 97%, 98.3%, and 98.3% of cases, respectively. Discussion and Conclusion: While anatomy educators and students understand that anatomic structure has an inherent range of variability, the classic axillary artery branching pattern students expect to find in cadavers and patients rarely occurs. Educators must present a realistic picture of anatomic complexity and emphasize the clinical and surgical implications of anatomical variation.

Comparative anthropometry analysis of the digital X-rays of the right and left hip joints in an Indian population

Background: Population-specific anthropometric analysis of hip joints has vital clinical and surgical implications including adoption of optimal preventive measures and selection of effective prosthesis. Hence, in this study, we determined the anatomical variance between the right and left hip of the patients referred to our orthopedic unit. Materials and Methods: Five hundred patients with a normal hip joint attending the Institute of Orthopedics and Traumatology Unit of Coimbatore Medical College Hospital, Coimbatore, India, were included in this study. Plain radiographs were taken to measure the neck-shaft angle (NSA), head diameter (HD), neck width (NW) of the right and left femur, and the values were compared with data reported in the literature for various other population. Results: The mean value of NSA (134.2°), HD (42.9 mm), and NW (28.2 mm) in the study population differed when compared with data reported in the literature for the Western and other Indian population. Significant changes were also observed between the right and left sides of the hip joint in the study population. Conclusion: This study concludes that significant differences exist between the right and left side of hip joint in the study population. Further the values observed in our study population were considerably different from the values reported in the literature for the Western population.