Unusual Anatomical Variation Research Articles

Vascular complications during appendectomy: severe adhesion of the appendix to the right iliac artery: a case report

IntroductionAppendicitis is a common cause of acute abdomen. Rarely, it may form adhesions to nearby structures, complicating surgeries, especially when involving vascular structures such as the internal iliac artery, potentially causing severe intraoperative hemorrhage.Case presentationA 65-year-old Middle Eastern male presented with abdominal pain and anorexia for 5 days. Examination and imaging confirmed acute appendicitis with complications. Additionally, a large pelvic mass was noted. During surgery, severe bleeding was encountered due to an adhesion between the appendix and the right internal iliac artery, managed by ligating the artery. The patient recovered well and was discharged in stable condition. Histopathology confirmed the diagnosis.ConclusionThis case highlights a rare vascular complication of appendectomy due to abnormal adhesions between the appendix and the internal iliac artery, associated with a large pelvic mass. This study emphasizes the need for thorough preoperative evaluation and careful surgical planning in patients with unusual anatomical variations or specific underlying conditions such as neurofibromatosis. Early recognition and strategic management of vascular adhesions are essential to optimize patient outcomes in appendectomies complicated by such rare scenarios.

Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging’ revisited: a case-report

BackgroundPeople with achondroplasia exhibit distinct physical characteristics, but their cognitive abilities remain within the normal range. The challenges encountered during surgical procedures and perioperative care for achondroplastic individuals, are underrepresented in the existing literature.Case presentationIn this report, the management of a 26-year-old North-African achondroplastic male is highlighted. The patient suffered a complete intra-articular distal femur fracture (AO/OTA 33-C1) and an ipsilateral patella fracture (AO/OTA 34-C1). The patient’s unusual anatomical variations and the lack of suitable orthopedic implants posed significant surgical challenges, particularly in the context of a resource-limited developing country. Facial and spinal deformities, which are common in patients with achondroplasia, further complicated the anesthetic approach.ConclusionsThe limited information on operative management of fractures in achondroplastic patients necessitated independent decision-making and diverging from the convenient approach where clear guidance is available in the literature.

Subtotal cholecystectomy as an approach to preventing injury in the left-sided gallbladder in the emergency surgery setting: A case study

A left-sided gallbladder is an unusual anatomic variation that makes gallbladder surgery challenging. Two systematic reviews on surgery for left-sided gallbladder highlighted high iatrogenic bile duct injury rates of 4.4% and 7.3%. This paper reports a female in her 40s with symptoms of acute calculous cholecystitis admitted to a secondary health-care center. After inserting four ports through standard sites for conventional gallbladder surgery, laparoscopic inspection revealed a phlegmonous left-sided gallbladder. No discordant situs of abdominal viscera was noted. Laparoscopic surgery was converted to open subtotal closed-tract cholecystectomy. No post-operative complications related to the surgical site were observed. A left-sided gallbladder affected by severe inflammation and infection is an extraordinary condition that should be considered as a risk factor. If an inflamed left-sided gallbladder is encountered, emergency subtotal cholecystectomy is an alternative to total cholecystectomy when the circumstances to adopt the strategies of a culture of safety in cholecystectomy for complete removal of the gallbladder are unfavorable. Relevance for Patients: Subtotal cholecystectomy in patients with left-sided gallbladder reduces the risk for bile duct injuries, outweighing the potential side effects stemming from this surgical approach.

An Unusual Anatomical Variation of Accessory Left Gastric Artery Arising from Left Hepatic Artery

An Unusual Anatomical Variation of Accessory Left Gastric Artery Arising from Left Hepatic Artery

Unusual Anatomic Variation: Intradural Conjugation of the Hypoplastic Left ICA and the Enlarged Accessory Meningeal Artery

The precise definition of the accessory meningeal artery was not available until 1961. It can originate from the maxillary artery or middle meningeal artery and supplies the meatus and membranous portion of the auditory tube, the lateral pharyngeal muscle, and the medial pterygoid muscle; Laterally, it supplies the lateral pterygoid muscle, the extracranial part of the mandibular nerve, the pterygoid venous plexus, and the sphenoid periosteum. Here, we present a 70-year-old male patient who applied to the neurosurgery clinic with complaints of chronic headaches and dizziness. Magnetic resonance angiography and computed tomography angiography showed hypoplasic appearance of the left internal carotid artery and an enlarged accessory meningeal artery variant merging with its ophthalmic segment.

Three-rooted Maxillary Premolar: A Case Report of an Unusual Anatomic Variation

Three-rooted Maxillary Premolar: A Case Report of an Unusual Anatomic Variation

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

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

Surgery in the Area of Accessory Infraorbital Foramen and Nerve: Cone-Beam Computed Tomography versus Intraoperative Appearance

We present a unique comparison of cone-beam computed tomography (CBCT) and intraoperative view of the accessory infraorbital foramen and nerve in a 60-year-old woman who was surgically treated due to the giant dentigerous cyst of the maxillary sinus from ectopic upper third molar. CBCT imaging demonstrates highest level of accuracy in verification of the accessory infraorbital foramina what makes this imaging technique a perfect tool for the surgery planning in the area of middle face. Avoidance of iatrogenic trauma of both infraorbital and accessory nerves will be ensured significantly in professionals who understand this topic. Oral and maxillofacial surgeons and doctors of neighboring specialties should be aware of such unusual anatomic variation as unilateral or even bilateral accessory infraorbital foramina and intraosseous nerve ramification.

VP010 INTRA-ABDOMINAL HERNIA AS A CAUSE OF ACUTE SMALL INTESTINE OBSTRUCTION. LAPAROSCOPIC EMERGENCY TREATMENT - SMALL INTESTINE OBSTRUCTION DUE TO INTERNAL HERNIA WITH CONCOMITANT ACALCULOUS CHOLECYSTITIS

Abstract Aim Nowadays, in vast majority of emergency patients with gastrointestinal obstruction laparoscopy is not the treatment of choice. In our department laparoscopy is routinely used in emergency admitted patients, also those with abovementioned condition, sometimes yielding unexpected and thrilling results. The aim of this work is to present a laparoscopic internal hernia repair with simultaneous “Phrygian-cap-type” gallbladder excision, performed on a patient with small intestine obstruction and chronic acalculous cholecystitis. Material and Methods A 57-year-old patient was admitted to our department as an emergency, with a one week history of symptomatic cholecystitis accompanied by gastrointestinal obstruction. CT revealed atypical suprahepatic displacement of the small intestine. An attempt of conservative treatment failed after the re-initiation of oral nutrition. The patient was qualified for laparoscopy. Results An anatomical variant of the liver ligaments was visualized with two defects in the anteriorly displaced coronary ligament and shortening of the falciform ligament. Those defects formed the hernia ring entrapping a small intestine of a total length of about 1.5 m. The falciform ligament was dissected. To avoid re-entrapment of the intestine, most of the coronary ligament was severed. Consecutively the inflamed gallbladder was removed. The unusual anatomical variation of its structure, the so-called “Phrygian cap”, was an additional difficulty. The postoperative course was uneventful. Conclusions The presented material demonstrates the possibility of immediate treatment of intestinal obstruction, even in a complicated cases, with laparoscopic manner, without the need of conversion to the open method.

Possible points of compression of the ulnar nerve: Tricks and traps that await clinicians from an anatomical point of view.

The ulnar nerve can be subject to numerous types of compression. The most common are cubital tunnel and ulnar tunnel syndromes, but there are many others with more uncommon etiologies. The existence of additional communicating branches, median nerve involvement, various types of injuries, and unusual anatomical variations can be a challenge for both diagnosis and treatment. This review presents a comprehensive depiction of ulnar nerve entrapment syndromes with particular reference to their anatomical background, risk factors, and clinical evaluation. Even common disorders can result from atypical morphological changes. It is important to be familiar with them as it is a key ability in daily medical practice.

Safety and Efficacy Using the Second-Generation Cryoballoon in Patients With Atrial Fibrillation and a Common Ostium of Inferior Pulmonary Veins.

Background: Common ostium of inferior pulmonary veins (COIPV) is a kind of pulmonary vein variation. The safety and efficacy of COIPV isolation using the second-generation cryoballoon (CB) ablation remain unknown.Methods: A total of 10 patients with COIPV from a consecutive series of 1,751 patients with atrial fibrillation (AF) were included. Pulmonary vein isolation (PVI) was performed using the second-generation CB.Results: The prevalence of a COIPV was 0.57% in this study. PVI was achieved in all pulmonary veins (PVs) without the need for a touch-up. A segmental freeze strategy was applied for each inferior PV, respectively. The mean number of freeze cycles of inferior PVs was 1.4 ± 0.5 for the left inferior pulmonary vein (LIPV), and 2.0 ± 0.9 for the right inferior pulmonary vein (RIPV). Pulmonary vein potential (PVP) of RIPV could not be monitored in real-time in three cases. Eight of 10 patients (80%) were free from atrial arrhythmias without the use of antiarrhythmic drugs during a follow-up period of 23.6 ± 12.9 months. No procedure-related complications occurred in any of the 10 patients.Conclusions: Common ostium of inferior pulmonary veins is a rare but challenging PV variant. PVI with this unusual anatomic variation using the second-generation 28-mm CB is effective and safe.

Toraks Bilgisayarlı Tomografisinde Tesadüfen Saptanan Nadir Bir Anatomik Varyasyon: Azigos Lobu

Aim: An azygos lobe is an unusual anatomical variation of the upper lobe of the right lung. During the formation of the lungs, the right azygos lobe develops as the precursor of the azygos vein, moving along the pleural surface rather than arcing forward above the origin of the lung to reach the upper vena cava, enters the apex of the right lung in the upper thoracic region. The purpose of this study was to assess the prevalence of the right azygos lobe in a sample of the Turkish population.Methods: This study was conducted from February to October 2020. Each computed tomography (CT) scan was checked for the presence of a right azygos lobe and a fissure on the axial plane. The azygos lobe was described as the convex line in the paramediastinal portion of the upper right lung on the CT scan. Our exclusion criteria were previous thoracic surgery in the right lung or parenchymal distortion on CT examinations.Results: One thousand nine hundred and sixty-five thorax CT scans were evalu¬ated retrospectively. Nine hundred and forty-five of them were from men and the remainder were from women. A total of 15 right azygos lobe variations were detected (six females, nine males). The mean age of the patients was 52.87 ± 14.604 years (30–77). The azygos lobe frequency was 0.76%.Conclusion: The azygos lobe is typically an uncommon variation of the right lung and is not really a distinct lobe. It is a very important variation that should be known about as it can mimic pathological conditions such as cysts, abscesses, or lung le¬sions. Since the azygos lobe is usually an incidental finding, radiologists and sur¬geons should be aware of this this potential anomaly during the imaging and inter¬ventional procedures.

Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance

Background: Critical limb ischemia (CLI) has been a burden on society where revascularization of arteries is the first line of treatment. If the antegrade approach is not possible, retrograde approach through pedal–plantar loop can be done, resulting in better prognosis. For the same reason, assessment of blood vessels of foot in general is practiced before any intervention. Having information about normal anatomy and anatomical variants of these blood vessels could be of great help to the interventionist to reduce the postoperative complications. Context: The authors studied formation of plantar arterial arch, normal anatomy, and anatomical variations in plantar metatarsal arteries (PMTAs) regarding their origin in 50 formalinized adult cadaveric feet. Results and Conclusion: Variations in formation of plantar arterial arch as predominant lateral plantar artery supplying to most of the PMTAs were noted. Common stump of origin for the first and second, then for second and third, and also for the third and fourth PMTAs was found. In two feet, we found common stump of origin for the first PMTA and first dorsal metatarsal artery originating from deep plantar arch. Medial branch from medial plantar artery joined the first PMTA to supply the great toe deep to the transverse metatarsal ligament. In about 28% of specimens, the foot length was ranging from 21.1 cm to 22 cm and the distance between the plantar arterial arch and the posterior margin of heel was ranging between 12 and 13.5 cm. Fibular plantar marginal artery was present in all specimens. Implications: In the retrograde approach for the revascularization in cases with CLI, most of the surgeons are trying the approach through plantar pedal loop or direct puncture of metatarsal arteries. Data collected on plantar metatarsal normal anatomy and anatomical variations can be kept in mind while doing any intervention with better prognosis.

Common Internal Iliac Vein Joining Inferior Vena Cava—a Rare Anatomical Variation: Anatomic and Surgical Relevance

An unusual anatomical variation of the internal iliac veins (IIV) was found in a 26-year-old lady who was undergoing retroperitoneal lymphadenectomy for a recurrent ovarian cancer. Intraoperatively the right and left internal iliac veins were converging to form a common trunk which was draining into the inferior vena cava along with the right and left external iliac veins. These anomalies result from the persistence of the embryonic inferior branch of the cardinal vein. Prior knowledge of these variations facilitates the safe performance of retroperitoneal, pelvic, and laparoscopic surgeries and also vascular interventional procedures involving these areas.

Unusual anatomies: case series

Aim: The aim of this article is to describe three case reports of unusual teeth anatomy, more precisely of a maxillary right central incisor with two roots and two root canals, a mandibular premolar with four root canals and a second maxillary molar with five root canals associated with an extra small root located in the center of pulp chamber. Methodology: A correct diagnosis, the awareness of finding an unusual anatomic root variation in any endodontic treatment, the use of technological equipment like the operative microscope and ultrasonic tips enabled the operator to solve the clinical case in a safe and predictable way. In order to set a correct treatment plan, it is quite important to evaluate a pre-operative radiograph before starting the endodontic treatment. Another step is the thorough examination of the pulp chamber floor, better if carried out under magnification and coaxial light in order to easily locate all the canal orifices. The endodontic treatment and retreatment of the previously mentioned three uncommon teeth will be discussed. Results: All the root canals were found, treated and obturated in the three presented cases and healing was shown in the follow up radiographs. Conclusions: Anatomic root variations should be anticipated in order to be encountered in the daily endodontic practice. A pre-operative radiography must always be done before endodontic treatment in order to make the right diagnosis. The operative microscope magnification is useful in order to work in a safe and precise way.

Unusual anatomical variation in formation of sural nerve

Background: Sural nerve is formed by communication of medial sural cutaneous nerve, that arise from tibial nerve in popliteal fossa and peroneal communicating nerve, a branch directly from common peroneal nerve or from lateral sural cutaneous nerve.The objective of this study was described an unusual and few reported anatomical variation in formation of sural nerve.
 Materials and Methods: The anatomical variation described was found during routine dissection performed by medical students of second semester in two maleembalbed adult cadavers of 75 and 65 years of age, respectivelyin the laboratory of Morphology of the University of Pamplona.
 Results and Discussion: In the left lower limb, both medial sural cutaneous nerve, and lateral sural cutaneous nervewere absent. The sural nerve arose directly from the tibial nerve. It’s observed a communicating branch between tibial nerve and common peroneal nerve. In the right lower limb, lateral sural cutaneous nerve was absent. The sural nerve arose directly from the common peroneal nerve.Peroneal communicating nerve was considered as absent in the two cases.Motor fiber from sural nerve to gastrocnemius muscle was observed in both lower limbs
 Conclusions:The knowledge of the sural nerve (normal anatomy and variations in origin and course) is important in evaluating of the patients, as well explaining the different clinical findings necessary for accuracy treatment.
 Bangladesh Journal of Medical Science Vol.18(3) 2019 p.508-512

Usefulness of Cone-Bean Computed Tomography Exams to Detect Foramen of Huschke in Diverse Age Group.

The foramen of Huschke (FH) is present in the early stages of the temporal bone tympanic portion development. The literature shows that FH may persist in adult individuals and several authors acknowledge its clinical importance, reporting being associated with the dissemination of diseases. Some authors believe that FH presents importance in archeology and forensic situations.Considering that the identification of FH by conventional imaging methods is extremely impaired or impossible due to overlapping bone structures and that cone-bean computed tomography presents quality in the evaluation of this structure, the authors conducted this research to determine the FH prevalence and dimensions through the Invivo5 software, and correlated its size with age.The foramen was present in 19 scans (12.7%), 6 (8.8%) were present among male and 13 (15.8%) among female. The χ test was performed, with no statistically significant difference for gender and age. Considering the age, in individuals aged 7 to 18 years, 16.4% of persistent FH was found compared with 10.5% in individuals over 18 years of age. The diameter ranged from 2.58 to 3.28 mm. No correlation was found between size and age (p between 0.25 and 0.88).The authors conclude that the cone-bean computed tomography is an examination that allows the correct evaluation of the FH and, although the persistence of this unusual anatomical variation presents different frequencies in the different populations and age groups, it can have clinical consequences, so that the professionals who work in the area must be aware of its existence.

Anatomical Variation Of The Submandibular Gland Duct. A Unreported Anomaly

Background: The submandibular gland is the second largest major salivary gland and weighs 7–16 gr. The gland is located in both sides of the face, at the same level of the body of the jaw, in the submandibular triangle, The submandibular duct or Wharton’s duct exits anteriorly, coursing deep to the lingual nerve and medial to the sublingual gland, the main excretory duct of the submandibular gland, whose diameter is of 2 to 3mm and approximately 4–5 cm long. It empties lateral to the lingual frenulum through a papilla in the floor of the mouth behind the lower incisor tooth. The purpose of this study is determine the morphologic features and describe an unusual anatomical variation of the path of the submandibular duct.
 Methods and Findings: A total of 17 cadavers were used for this study in the Morphology Laboratory at the University of Pamplona. In a cadaver were findings: The excretory duct of the left submandibular gland had an external location that ascends and crosses vertically off the body of the mandible, in its termination it is divided in four ducts that had separate openings into the oral cavity upon a small papillas independent, opposites to the first and second lower molar Crown.
 Conclusions: Awareness of potential variations of the excretory ducts of the salivary glands can aid in the accurate diagnosis and treatment of patients with salivary conditions as well as help surgeons avoid further complications or duct lacerations during surgical procedures.

First line direct access for transarterial embolization of a dural arteriovenous fistula: Case report and literature review

Intracranial dural arteriovenous fistulae (DAVF) are complex vascular malformations consisting of a pathological shunt located between meningeal arteries and drainage to dural venous sinuses and/or cerebral veins. We report an unusual anatomical variation, resulting in a DAVF forming between the superior sagittal sinus and an anomalous origin of the middle meningeal artery (MMA) arising from the left ophthalmic artery. We present an atypical case requiring mini-craniotomy for catheter access, as well as cannulation of extracranial arterial supply prior to embolization of a Cognard type IIa+b fistula. Due to structural variation, transarterial endovascular embolization was deemed too high risk owing to risk of permanent blindness. We present a technical note and literature review on the first documented case of combined endovascular and surgical intervention as first line treatment for embolization of an anomalous middle meningeal artery related fistula. Our approach provided adequate obliteration of the DAVF and may be an alternative way to treat DAVF, when traditional transarterial or transvenous approaches are deemed high risk for neurological deficit.

Une artère sciatique persistante révélée par une ischémie aiguë du membre inférieur droit : à propos d’un cas

The Persistent Sciatic Artery (PSA) is an unusual anatomical variation due to the persistence of an embryological artery, which should disappear before the 3rd month of intrauterine life. The reported case is that of a woman who developed an acute ischemia of the right lower limb, revealing the presence of persistent sciatic artery. Diagnosis was made only belatedly by means of angio-CT. The amputation was the inevitable choice of treatment.