Anatomical Variations Research Articles

Rhinolith Within a Giant Concha Bullosa: A Case Report and Review of Literature.

Concha bullosa is a common anatomical variation involving pneumatization of the middle turbinate. Although usually asymptomatic, a large concha bullosa can obstruct nasal airflow and cause related symptoms. Rhinoliths, calcified formations typically found in the inferior meatus, rarely appear within concha bullosa. This report presents a rare case of a rhinolith within a giant concha bullosa in a 15-year-old male experiencing progressive, unilateral nasal obstruction. Computed tomography (CT) revealed a densely-calcified mass inside of an extensive concha bullosa, accompanied by nasal septal deviation and maxillary sinus opacity. The patient underwent successful endoscopic sinus surgery with excision of the concha bullosa's lateral and medial laminae, facilitating complete rhinolith removal and correction of septal deviation. Postoperative follow-up over 6 months showed complete symptom resolution with no recurrence. This case underscores the importance of CT imaging in evaluating unusual nasal obstructions and highlights endoscopic sinus surgery as an effective approach for extensive concha bullosa. The findings emphasize careful consideration of anatomical variations in clinical practice and contribute to the limited literature on rhinolith formation within concha bullosa. Further studies are warranted to understand the pathogenesis of rhinoliths in nasal anatomical variations.

Images in Vascular Medicine: Internal carotid artery anatomic variation alters treatment for high-grade stenosis.

Images in Vascular Medicine: Internal carotid artery anatomic variation alters treatment for high-grade stenosis.

Bilateral asymmetrical variation of median artery in coexistence with bifid median nerve and variation in the origin and course of its palmar cutaneous branch: a case study with clinical implications.

The median artery typically regresses after two months of intrauterine life, although it may persist into adulthood in some individuals. The presence of a persistent median artery (PMA) may be associated with other anatomical variations including a bifid median nerve. In the present cadaveric study, we report a rare variation of bilateral asymmetry of PMA associated with the bifid median nerve, and unilateral variation of the origin and course of the palmar cutaneous branch of the median nerve (PCBMN) which to our knowledge, is the first study to report all these variations in an individual. Classical dissection of the upper limb was performed on a 45-year-old male cadaver. The cadaver was donated to the Department of Anatomy at Kerman University of Medical Sciences. Bilateral PMA was observed in both upper limbs. The PMA originated from the ulnar artery and contributed to the formation of an incomplete superficial palmar arch (SPA) on both sides; however, the branching pattern of these arteries was different between the right and left hands. Also, a bilateral high division of the median nerve was observed proximal to the carpal tunnel. We also encountered a very rare variation of PCBMN, in which it originated from the ulnar side of the median nerve, and passed beneath the flexor retinaculum of the left hand. Awareness of anatomical variations of the median nerve and also the presence of PMA is of utmost importance due to their implication in carpal tunnel syndrome and surgical complications.

Retrostyloid and retromandibular courses of the external carotid artery.

The external carotid artery (ECA) branching pattern has been extensively studied in the current literature. However, its topographical variability has been barely reported. The aim of the current study was to assess the ECA in relationship with the styloid process (SP) and the mandible. 100 computed tomography angiograms were randomly selected and retrospectively investigated on the neck region for the ECA course in relation to the SP and the mandible. A retrostyloid course of the ECA was identified on 18 sides (9%). Six patients had a bilateral retrostyloid ECA, and six patients had a unilateral variant. The side and sexes did not affect the prevalence of this variant. The elongated SP or variable ossification of the stylohyoid chain did not affect the retrostyloid course. The ECA retromandibular course of type 1 (straight course deep to the ramus of the mandible) was identified in 30.5%, type 2 (lateral retromandibular loop) in 20%, and type 3 (lateral retromandibular loop behind the ramus of the mandible) in 45.5%. The side and sexes did not affect the prevalence of this variant. Our study enhances the current knowledge on the ECA topography. Both variants investigated in the current study, displace the ECA into the parapharyngeal space. Knowledge of these anatomic variations are of importance preoperatively to avoid iatrogenic injuries.

Comparaison of effectiveness of flexible intubation fibersocope versus bonfils fiberoscope in tracheal intubation of paediatrics with midfacial hypoplasia

ABSTRACT Background Airway management is one of the fundamental skills of an anesthesiologist. When compared to adult patients, the pediatric patients have notable anatomical and physiological variations. These variations affect the methods and equipment the anesthesiologist will select to provide safe airway management. Purpose The purpose of the study aimed to compare the effectiveness of first intubation attempt while utilizing flexible intubation fiberoscope versus Bonfils fiberoscope in tracheal intubation of pediatrics with midfacial hypoplasia. Also, to estimate time to first intubation attempt, time to endotracheal insertion and to assess the occurrence of complications. Methods This randomized controlled trial was conducted over 30 children (aged 6 month up to 5 years) with midfacial hypoplasia planned to undergo elective surgery while under general anesthesia. The children were categorized in random to two equal groups: group I intubation was with Karl Storz flexible intubation fiberoscope 3.7 mm via AirQ-ILA, while group II intubation was with Storz Bonfils fiberoscope 3.5 mm. Success of first attempt of intubation, time to first attempt of intubation, time to endotracheal insertion, number of intubation attempt, complications were recorded. Results No notable variations were observed in the success of first attempt of intubation between the two groups. The time to first attempt of intubation and the time to endotracheal tube insertion were significantly less in group II than in group I where p > 0.001. Regarding the number of intubation attempt and the occurrence of complications, the two groups did not significantly differ from one another where p = 1.000. Conclusion The Bonfils fiberoscope and the flexible intubation fiberoscope are both appropriate tools for intubating pediatrics with midfacial hypoplasia. However, Bonfils fiberoscope was superior with regard to the time to first attempt of intubation and the time to endotracheal tube insertion.

The accessory renal arteries: A systematic review with meta-analysis.

The accessory renal arteries (ARAs) are a well-described variant of the renal vasculature with clinical implications for radiologists, surgeons, and clinicians. The aim of the present systematic review with meta-analysis was to estimate the pooled prevalence of ARAs, including their variant number, origin, and termination, and to highlight symmetrical and asymmetrical morphological patterns. The systematic review used four online databases in accordance with PRISMA 2020 and Evidence-based Anatomy Workgroup guidelines. R programming software was used for the statistical meta-analysis. A total of 111 studies were considered eligible for our initial aim. The typical renal artery (RA) anatomy (a single bilateral vessel) was identified in 78.92%; the overall ARA prevalence was estimated at a pooled prevalence of 21.10%. The estimated pooled prevalence of one, two, three, and four ARAs were 18.67%, 1.80%, 0.01%, and <0.01%. The ARAs have been the subject of extensive research owing to their clinical importance, including in kidney transplantation surgery and resistant hypertension therapy. Knowledge of the typical and variant anatomy of RAs is essential for anatomists, radiologists, surgeons, and clinicians in order to avoid misunderstanding, complications, and iatrogenic injury.

Rouvière's Sulcus as a Landmark for a Safe Laparoscopic Cholecystectomy: An Interim Analysis of a Multicenter Cross-sectional Study on the Prevalence and Morphologic Type of Rouvière's Sulcus in the Italian Population.

Laparoscopic cholecystectomy is the gold standard in the treatment of symptomatic gallstones. The large number of gallbladders removed every year is not fully consistent with the excessively high incidence of iatrogenic bile duct injury (IBDI). Several strategies have been suggested to reduce this risk. Among them, the use of extra biliary anatomic structures, such as the Rouvière's sulcus, as a landmark to guide the surgeon during dissection has been proposed as a means to prevent IBDI. The main aim of the present paper is the evaluation of the prevalence of Rouvière's sulcus (RS) and its anatomic variants in a given population. This observational, cross-sectional, and multicenter study has been conducted at the Department of Digestive and Emergency Surgery of the "Azienda Ospedaliera Santa Maria," Terni (Italy), at the Department of Surgical Sciences of the "Azienda Ospedaliera Perugia," Perugia (Italy) and at the Department of Emergency and Trauma Surgery of the "Policlinico Umberto I," Rome (Italy). Intraoperative images of 111 patients undergoing laparoscopic cholecystectomy were analyzed to identify the presence and type of RS, according to the Singh-Prasad classification and the Dahmane classification. RS was present in 93 (83.8%) patients. Singh-Prasad type 1A is present in 48.4% of patients, type 1B in 25.8%, type 2 in 12.9% and type 3 in 12.9%. Dahmane's open type is present in 48.4% of patients and fused type in 51.6%. Due to its high prevalence, RS can be used as an anatomic landmark and probably reduces the incidence of IBDI during laparoscopic cholecystectomy.

Tunable and real-time automatic interventional x-ray collimation from semi-supervised deep feature extraction.

The use of endovascular procedures is becoming increasingly popular across multiple clinical domains. These procedures are generally performed under image guidance using an interventional c-arm x-ray system. Radiation exposure to both patients and interventional staff due to use of fluoroscopy is a health and occupational concern, but modifications to the interventional workflow to address radiation may come at the cost of procedure time orquality. Interventional x-ray collimation is a crucial task for improving image quality as well as reducing radiation exposure to both patients and operators who work in the x-ray domain. However, collimation is heavily underutilized due to its cumbersome nature and the difficulty of manually manipulating multiple parameters during fast-paced interventional procedures. Additionally, the widely varying collimation preferences of interventionalists across different procedure types, procedure phases, and anatomies makes the standardizing of collimation challenging for radiation technologist supportstaff. Automating collimation has the potential to bridge this gap, freeing up mental bandwidth for interventionalists and technologists and improving outcomes for patients. Here, we propose a tunable algorithm for automatic collimation based on a region-of-interest optimizer driven by a combination of image, system, device, and radiation based features and we illustrate its efficacy across varying personal preferences. Critically, we devise a method with a simple and easily understandable mapping between algorithm parameters and practicaloutcomes. We show a real-time implementation of this algorithm using deep feature extraction by a convolutional neural network and evaluate its performance in a custom dataset of simulated fluoroscopy and recorded fluoroscopy from clinical radial access procedures. We evaluate the effects of a practically implemented mixed supervision training strategy on model performance and show potential for radiation reduction in simulation. An uncertainty analysis indicates that the algorithm is robust to noise and anatomical variation across our clinical dataset. Clinical acceptability and quality is evaluated through a reader study with expert neuro-interventional radiologists, with participants indicating 100% clinical acceptability, high quality ratings, and improved radiation protection over their typicalpractice. The algorithm's modular design ensured that users' collimation requirements were met without disruption to the interventional workflow or procedure time, while exhibiting strong potential to reduce radiation risk to patients and operators. Evaluation in more varied clinical settings could support translation of this technology into theclinic.

The Safety and Feasibility of Aquablation in Patients with Previous Surgery for Benign Prostatic Hyperplasia.

Objective: Aquablation for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) has been adopted to treat a wide range of prostate anatomies including glands up to 150 cc. Patients with recurrence of LUTS after previous BPH procedure often present with variant anatomy, and a paucity of literature exists on the optimal treatment modality for these patients. Herein, we evaluate the safety and feasibility of aquablation in patients with previous BPH surgical history. Patients and Methods: A prospectively managed single institution database of aquablation patients with BPH/LUTS was queried from August 2020 to December 2022 for patients who failed previous BPH procedures. Patients were divided into two groups: those with and without previous BPH procedure. Primary outcomes were intraoperative and 90-day complications. Secondary outcomes included operative time (OT), number of Aquabeam passes, estimated blood loss, hospital length of stay, and catheter duration. Outcomes were assessed using chi-squared, Wilcoxon rank sum tests, and logistic regression. Results: A total of 200 patients with BPH/LUTS were treated with aquablation. We identified 26 patients with a history of previous BPH procedures. Patients who underwent previous BPH procedures had smaller prostate volumes (60 cc) compared with treatment-naïve (88 cc) patients, p = 0.016. There was no difference in perioperative and 90-day complications (29% for treatment-naïve vs 17% in the retreatment group, p = 0.32). Most secondary outcomes were the same including OT, but the retreatment group had fewer Aquabeam passes (2 [1-2] vs 2 [2-2] treatment-naïve, p = 0.037) and more additional procedures at follow-up (30% vs 8.3% treatment-naïve, p = 0.005). Conclusion: Patients with previous BPH interventions remain excellent candidates for aquablation, with similar perioperative and 90-day postoperative outcomes compared with intervention-naïve patients. Aquablation demonstrates efficient tissue ablation without the risk of increased injury or significant blood loss after prior failed BPH procedures.

The Impact of Intraoperative CT-Based Navigation in Congenital Craniovertebral Junction Anomalies: New Concepts of Treatment

Background: Congenital craniovertebral junction anomalies (CCVJAs) encompass a diverse range of conditions characterized by distorted anatomy and significant variation in the pathways of neurovascular structures. This study aims to assess the safety and feasibility of tailoring posterior fixation for CCVJAs through intraoperative CT-based navigation. Methods: An in-depth retrospective analysis was conducted on eight patients diagnosed with CCVJAs (excluding Arnold–Chiari malformation). These patients underwent posterior fixation/arthrodesis facilitated by intraoperative CT-based navigation. The analysis included an examination of the fixation strategies, complication rates, length of stay, post-operative complications, and success of arthrodesis. Additionally, a comprehensive literature review was undertaken to contextualize and compare our findings. Results: Patients undergoing CVJ posterior fixation with intraoperative CT-based navigation exhibited a flawless record, devoid of complications related to the damage to neurovascular structures, as well as any instances of screw misposition, pullout, or breakage (0 out of 36 total screws). Furthermore, the entire cohort demonstrated a 100% arthrodesis rate. None of the patients required treatment with an occipital plate. Conclusions: The incorporation of intraoperative CT-based navigation proves to be an invaluable asset in executing CVJ posterior fixation within the context of CCVJAs. This technology facilitates the customization of posterior constructs, a crucial adaptation required to navigate the anatomical challenges posed by these anomalies. The secure placement of screws into the occipital condyles, made possible by navigation, has proven highly effective in achieving CVJ fixation, obviating the need for an occipital plate. This technological leap represents a significant advancement, enhancing the safety, precision, and overall outcomes for patients undergoing this surgical procedure, while concurrently reducing the necessity for more invasive and morbid interventions.

Anesthesiologists Cross the Quality Chasm with Point of Care Ultrasound (POCUS) Among Perioperative Patients

Background/Objective: POCUS is an invaluable tool for anatomical variation assessment, guidance of invasive interventions, and diagnosis of critical conditions that may change the anesthesiologist’s plan of care. This technology increases success rate, decreases time to surgery, and maximizes outcomes. The objective of this pilot program evaluation was to identify the anesthesiologists’ systems and processes for utilizing POCUS in clinical decision-making for patients during the perioperative phases of care for improved outcomes. Materials/Methods: A Multivariate Analysis of Variance (MANOVA) was conducted to identify differences across groups (scan type). The independent variable was the type of POCUS examination. The dependent variables included the patient’s: (1) Perioperative Status; (2) Cardiothoracic Anesthesiologist’s Review of Patient History and Formulating the Clinical Question; (3) Overall Risk Potential; (4) Aspiration Potential; (5) Issues Related to Cardiovascular Hemodynamics; (6) Issues Related to Volume Status; (7) Clinical Question Answered by POCUS; (8) Change in Plan of Care; (9) Interventions; and (10) Pharmacological Interventions. Results: MANOVA findings (Wilks’ λ) identified a statistically significant interaction between POCUS scan type and the cardiothoracic anesthesiologist’s clinical decision-making (p &lt; 0.0001). The following four criteria were statistically significant: (1) patients (64%) were examined with POCUS preoperatively (p &lt; 0.05); (2) patients (95%) identified as having some type of overall risk potential (p &lt; 0.05); (3) patients (36%) specifically identified as an aspiration risk (p &lt; 0.0001); and (4) patients (41%) identified with issues related to cardiovascular hemodynamics (p &lt; 0.001). Conclusions: POCUS is a proven imaging modality that is easy, portable, sensitive, and specific for identifying various anatomical landmarks. POCUS utilization in the perioperative setting has potential to have a profound impact on successful surgical completion.

Anatomical neuromuscular variations determined by magnetic resonance imaging in chronic pelvic pain

Background: The diagnosis of neuromuscular pelvic pain is challenging. Despite the increasing use of magnetic resonance imaging (MRI) in the assessment of pudendal neuralgia, there are limited data describing radiological variations of the nerve. Additionally, the utility of MRI in the assessment of pelvic floor tension myalgia is unknown. Aims: To describe the anatomical variations of the pudendal nerve and dimensions of pelvic muscles in patients investigated for neuromuscular pelvic pain using a combined MRI protocol. Materials and methods: A retrospective audit of MRI reports for 136 patients referred to a single radiologist was conducted. Reported data included the appearances of the pudendal nerve and its perineural structures, and the maximal thicknesses of pelvic muscles. Results: Several anatomical variations were identified in the course of the pudendal nerve at or above the ischial spine. Likely/highly likely nerve compression at this level was present in 34.6% of hemipelves. Variations associated with compression included delayed separation of the sacrospinous and sacrotuberous ligaments ( p &lt; 0.0001), close apposition of ligaments ( p &lt; 0.0001), interligamentous bands ( p = 0.033), coccygeal muscle contributions to the sacrospinous ligament ( p = 0.014) and proximal ( p &lt; 0.0001) and thickened falciform ligaments ( p &lt; 0.0001). Variations below the ischial spine were uncommon. Conclusions: This study represents a quantitative and qualitative expansion to the radioanatomical basis of pudendal nerve entrapment on MRI, and highlights the limitations of MRI obtaining reproducible measurements of pelvic muscles. Images from asymptomatic controls and further prospective evaluation of treatment outcomes is required to determine the clinical significance of MRI findings in the assessment of pudendal neuralgia.

Communicating artery between posterior circumflex humeral artery and deep brachial artery: case report, literature review and clinical implications.

Knowledge of a large communication between posterior circumflex humeral and deep brachial arteries, although infrequent, it is important to avoid damage during a Leechavengvongs procedure or used as recipient artery in free flaps for upper limb reconstruction. A dissection of a latex-injected cadaver revealed the presence of a large communication between the posterior circumflex humeral and deep brachial arteries. Furthermore, this communicating artery was observed during a Leechavengvongs procedure. A comprehensive review of the existing literature on the anatomical variations of the posterior circumflex humeral and deep brachial arteries was conducted. A communicating artery between the posterior circumflex humeral and deep brachial arteries was identified during a routine dissection. This communicating artery establishes a posterior collateral pathway of substantial caliber between the axillary and the brachial arteries. Given its oblique trajectory posteriorly along the humeral shaft, this artery is susceptible to injury during a posterior approach to the humerus. Despite the existence of numerous anatomical variations involving the posterior circumflex humeral and deep brachial arteries, this communicating artery has not been previously described in the literature. Additionally, we report this anatomical variation crossing the surgical field during a Leechavengvongs procedure. Our findings suggest that a large communicating artery between the posterior circumflex humeral artery and the deep brachial artery has the potential to cross the surgical field and become a source of risk during a posterior approach to the arm. It can also be used as recipient artery in free flaps for upper limb reconstruction.

Probing the limits and capabilities of diffusion models for the anatomic editing of digital twins

Numerical simulations of cardiovascular device deployment within digital twins of patient-specific anatomy can expedite and de-risk the device design process. Nonetheless, the exclusive use of patient-specific data constrains the anatomic variability that can be explored. We study how Latent Diffusion Models (LDMs) can edit digital twins to create digital siblings. Siblings can serve as the basis for comparative simulations, which can reveal how subtle anatomic variations impact device deployment, and augment virtual cohorts for improved device assessment. Using a case example centered on cardiac anatomy, we study various methods to generate digital siblings. We specifically introduce anatomic variation at different spatial scales or within localized regions, demonstrating the existence of bias toward common anatomic features. We furthermore leverage this bias for virtual cohort augmentation through selective editing, addressing issues related to dataset imbalance and diversity. Our framework delineates the capabilities of diffusion models in synthesizing anatomic variation for numerical simulation studies.

Anatomical Variations and Congenital Anomalies of the Gallbladder Observed during Laparoscopic Cholecystectomy

Anatomical Variations and Congenital Anomalies of the Gallbladder Observed during Laparoscopic Cholecystectomy

Overview of Anatomical Variations in the Vasculature of Suprarenal Gland and Its Applied Surgical Importance

Background: The suprarenal gland (SrG) presents a substantial circulatory supply compared to its size. The superior, middle, and inferior suprarenal arteries (SrA) have one or more duplicate major branches, which supply each gland. this study aimed to observe the variable arteries and veins of the SrG. As the vessels of SrG are forming extensive network, they may get damaged during different surgical procedures like adrenalectomy, renal transplant surgeries Methods: Present study conducted with Twenty five cadavers embalmed in 10% formalin. The inclusion criteria for study were intact blood vessels along with SrGs and the exclusion criteria included the damaged blood vessels and SrGs. Dissection was carried out as per standard dissection protocol. Results: Origin of right superior suprarenal artery from inferior phrenic artery and superior mesenteric artery, Origin of right superior suprarenal artery from aorta and some other findings were noted. Conclusions: This study highlights the critical importance of understanding the anatomical variations in the vasculature of the SrG, particularly in the context of surgical interventions such as adrenalectomy and renal transplantation. The intricate and variable nature of the blood supply to the SrG, including the SrA, as well as their venous drainage, presents significant challenges during surgery. KEY WORDS: Suprarenal Gland, Suprarenal Artery, Suprarenal Vein, Phrenic Vessels.

Levator Veli Palatini Muscle Ratio Is a Clinically Significant Anatomic Predictor for Velopharyngeal Surgical Need.

Velopharyngeal insufficiency (VPI) poses challenges for normal speech production, often necessitating surgical intervention. Determining optimal candidates for surgery remains complex and requires a nuanced understanding of underlying anatomic factors contributing to VPI. This study aimed to identify anatomic predictors that drive surgical recommendations for VPI. Prospective observational cohort study. Pediatric tertiary care hospital. Magnetic resonance imaging data were acquired from 150 children (aged 4-17) to identify anatomic predictors of VPI and surgical need. Fourteen velopharyngeal variables were measured in the oblique coronal and midsagittal imaging planes. Calculations included differences in levator veli palatini (LVP) muscle angles of origin, mean extravelar length, differences between left and right extravelar segments, the VP Needs ratio, and a newly developed LVP ratio. Multivariate logistic regression models with k-fold cross validation were utilized to identify anatomic profiles predictive of VPI and receiving a surgical recommendation. The models demonstrated high accuracy, sensitivity, and specificity. Among anatomic variables, the LVP ratio emerged as the strongest determinant of surgical need (β = 11.256, p < .001). Notably, an increase in the LVP ratio of 0.10 is associated with a 3.08-fold increase in the likelihood of receiving a surgical recommendation. LVP ratios above 1.0 were significant for both VPI classification and surgical need. The LVP ratio significantly differentiates individuals with VPI and is predictive of surgical need for VPI management. Inclusion of the LVP ratio into clinical evaluations may refine patient stratification, enabling more precise surgical decision-making tailored to individual anatomic variations.

Variations in Cystic Duct Anatomy Using Magnetic Resonance Cholangiopancreatography and their Clinical Significant in the Sudanese

Background: Anatomical variations of the cystic duct are very frequent, and it is substantial to be familiar with these variations preceding to any surgical, percutaneous and endoscopic intervention procedures.Objective: The aim of this study is to determine the normal (typical) and atypical anatomical variations in the cyst duct using magnetic resonance cholangiopancreatography at Fedail Specialized Hospital in Khartoum, Sudan.Materials and Methods: This study is a retrospective evaluation of the cystic duct in 307 patients who were routinely imaged with Magnetic Resonance cholangiopancreatography between November 2019 and March 2021 for various indications.Result: This study included 307 patients aged 6 months to 100 years, of whom 44.3% were male and 55.7% were female. The location, level, and course of the cystic duct were examined. The typical anatomy of the cystic duct was seen in only 30.29% of patients; this percentage is low compared to the range reported in the literature (58–75%). A total of 69.71.% showed atypical configurations. The most common variant was high cystic insertion, observed in 36.2% of cases. Low insertion was observed in 21.8%, low medial insertion in 14.6%, a spiral posterior course in 15.6%, and a parallel course in 10.1%. A short cystic duct less than 5 mm in length was seen in 1% of cases. Other rare findings include a case-for-case (0.3%): absent cystic duct; spiral anterior course with low medial insertion; spiral anterior then posterior; drainage of cystic duct to the right hepatic duct; drainage of the cystic duct at the junction between the right and left hepatic ducts; very high insertion just below the junction of the right and left hepatic ducts; and finally, a case of common bile duct cyst. The relationship between the location, height, and course of the cystic duct and gender was examined, and the result of the chi-square test showed that there was no statistically significant difference between males and females with regard to anatomical variations (p = 0.740). (p=0.671) (p=0.678).Conclusion: The normal anatomy of the cystic duct is observed in only 30.29% of cases. Anatomical variations are encountered in 69.71% of cases, with high insertion of the cystic duct being the main variation observed in 36.2% of cases; the next most common variation is a low insertion in 21.8% of cases.

A prospective and retrospective observational study on residual gallbladder stones after cholecystectomy

Background: A small number of post-cholecystectomy syndrome cases result from residual stones in a lengthy cystic duct or recurrence of lithiasis in a remaining gallbladder (GB) tissue. In laparoscopic procedures, up to 13.3% may involve incomplete GB removal due to surgical complexities and anatomical variations such as adhesions or challenging morphology. Aims and Objectives: (1) To assess the incidence of retained stones in patients undergoing cholecystectomy, (2) to compare incidences among open and laparoscopic cholecystectomies, (3) to study various presenting ways and different investigational methods helping in early diagnosis and proper management, and (4) to study different operative interventions for different cases. Materials and Methods: This was a prospective and retrospective observational study. After getting ethical committee approval and informed consent, 35 patients were included in the study. The study was carried out in the Department of General Surgery at I.P.G.M.E.R./S.S.K.M. Hospital, Kolkata. Results: Most patients were post-open cholecystectomy cases. The incidence of retained GB stones was 4.48%, with females affected 2.8 times more than males. Common symptoms were pain abdomen (80%) and fever (25%). Ultrasonography diagnosed stump calculi in 85.71% of cases; magnetic resonance cholangiopancreatography (MRCP) was preferred when ultrasound was inconclusive. Conclusion: Cases underwent subtotal cholecystectomy or had long cystic duct stumps in rural hospitals, referred to tertiary hospital for further management. Symptoms included pain abdomen, fever, and sometimes jaundice. MRCP confirmed diagnoses before open re-exploration; completion cholecystectomy addressed residual stones for symptom relief and cure.

Anatomical variations of the marginal mandibular nerve

IntroductionThe Marginal Mandibular Nerve (MMN), despite being didactically described as being a unique branch of the other branches of the Facial Nerve, has in practice an abundant anatomical variation. Both in relation to its ramifications and the positioning of these in relation to the lower edge of the mandible, as well as its anastomoses along its path, play a fundamental role in the surgical strategy during the approach of this cervicofacial site, and can generate, as underestimated its characteristics, inadvertent injuries and motor consequences to the patient. ObjectiveTo analyze the types of anatomical variations of the MMN in relation to its position, ramification, and distance from reference points, as well as its incidence that could imply technical difficulties in surgery. MethodsA systematic review was conducted in the literature in search of anatomical studies, in vivo or in cadavers, between 1981 and 2024, which described the quantification of the MMN branches, their positioning and peculiarities in relation to anastomoses with other peripheral nerves. Results511 hemifaces were studied, with the identification of 290 cases of single nerve, 160 cases of double branch, 54 cases of triple branch, and 7 cases of quadruple branch. Of the 456 nerves that were possible to study, the average distance when superior to the lower limit of the mandible was 1.61 cm, while its lower analysis was 2.53 cm. The branches presented different proportions of presentation in relation to this reference point depending on how many branches it had, being more common to remain below it. Anastomoses were identified between the MMN and the buccal and cervical branch of the Facial Nerve, as well as with the Trigeminal Nerve. ConclusionThe varied presentations of the MMN, both in its anatomical positioning and in the number of branches leads us to question whether the surgical thinking when performing an exploration in this site may not be the reason whythe authors verify several motor complaints superior to described injuries.