Variations In Vascular Anatomy Research Articles

Features of vascular anatomy in pancreaticoduodenal resection

In about 55–79% of patients, the vascular anatomy of the hepatic-pancreaticoduodenal area is characterized by a typical structure. In the rest of patients, the vascular and, primarily, arterial anatomy may vary due to both different variants of branches and additional arteries. Undoubtedly, this creates difficulties in surgical planning and performing pancreaticoduodenal resection. Vascular anatomic variations may contribute to increased intraoperative blood loss, postoperative complications, changes in the course and volume of surgery, and increased duration of hospital stay after surgery. Modern diagnostic methods, CT angiography in particular, facilitate the process of surgical planning and reduce the risk of unforeseen situations related to ligation or damage of arterial vessels, which are to be preserved during operations. In this work, we carry out a review of publications on the topography of arterial vessels in the area of pancreaticoduodenal resection. The issues related to anatomical variations in both trunk and pancreatic vessels are considered. Special attention is paid to the possible influence of variations in the vascular network structure on the course and volume of surgery, as well as the risk of intraoperative and postoperative complications.

802. TECHNICAL DETAILS: FREE JEJUNAL GRAFT AND REVERSE SAPHENOUS VEIN GRAFT FOR RECONSTRUCTION AFTER TOTAL PHARYNGO-LARYNGECTOMY AND PROXIMAL ESOPHAGECTOMY

Abstract Background We would like to show our tips for free jejunal graft and vascular reconstruction after pharyngo-laryngectomy and proximal esophagectomy. Methods 65 years-old man with history of hypopharynx squamous cell carcinoma cT3 cN0 cM0 who underwent radical Qt/Rt with initially complete response. After 2 years follow-up, he presented dysphagia and recurrence of squamous cell carcinoma proven by histology. Upper endoscopy shows cervical esophageal stenosis due to tumor infiltration. Rescue surgery was decided after systemic dissemination was ruled out with PET-CT. Results Pharyngo-laryngectomy, total thyroidectomy and proximal esophagectomy was performed. Free margin tumor was confirmed by frozen section. Jejunal segment with adequate vascular supply is selected, preferable with a single artery and vein. Peristaltic direction of the jejunum is marked to avoid mistakes during graft transposition. Division of mesenteric branches to prevent postoperative bleeding. Before jejunal section we recommend administration of hyoscine butilbromide 20 mg iv to avoid jejunal spams. Measuring the length graft needed before dividing the jejunum to avoid redundant or short graft is recommended. We must carefully isolate the pedicle avoiding damaging blood supply. To reduce time of ischemia, jejunal graft pedicle should not be ligated until cervical dissection is completed and we have ruled out if venous graft may be needed. After cervical artery and vein dissection, we ensure adequate blood flow and heparinize vessels before clipping. When dividing the pedicle, artery should be divided before the vein to avoid venous congestion, posteriorly we must heparinize the vessels. Povidone-iodine intraluminal washing is recommended. Jejuno-jejunal anastomosis for GI tract restoration. GI reconstruction first is recommended to avoid unnecessary traction on the vascular anastomosis. After ensuring adequate direction of the jejunal graft jejuno-esophageal anastomosis is performed with interrupted suture. Pharyngo-jejunal anastomosis is performed with barbed 3-0 running suture for anterior and posterior layer. Methylene blue test is performed for check the anastomosis. Vascular reconstruction technique depends on the vascular anatomical variations and availability. In this case, superior thyroid artery and sublingual vein were available. Saphenous vein graft might be needed, this graft must be used in reverse way to avoid the vein valves and length must be adjusted. Venous anastomosis should be performed before than arterial reconstruction after heparinize solution in both vessels to avoid thrombosis. Conclusion Free jejunal graft is a highly complex procedure that must be extremely coordinated and protocolized to avoid longer time of ischemia and risk of thrombosis that might compromise the graft viability. https://1drv.ms/v/s!AmFrct07P6MP1Fbyh_7Ce_OK5bB8?e=OMSjsK

FACTFINDERS FOR PATIENT SAFETY: Minimizing risks with cervical epidural injections

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections.Evidence in support of the following facts is presented.Minimizing Risks with Cervical Interlaminar Epidural Steroid Injections – 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks.Minimizing Risks with Cervical Transforaminal Epidural Steroid Injections – the Role of Preprocedural Review of Advanced Imaging -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes.Safety of Multi-level or Bilateral Fluoroscopically-Guided Cervical Transforaminal Epidural Steroid Injections -- Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.

Thigh Perforator Exchange: Intraflap Perforator Augmentation of Anterolateral Thigh Free Flaps.

Peripheral perfusion in large anterolateral thigh flaps may be inadequate if perforator zones are not properly planned during flap design and harvest, and variations in vascular anatomy can contribute to operative difficulty and morbidity. Intraflap anastomosis of extrinsic perforators may allow for augmentation of perfusion while avoiding significant intramuscular dissection. Adaptation of the perforator exchange technique, previously described in autologous breast reconstruction, optimizes vascular flow in anterolateral thigh flaps. Here, we present a technique for intraflap perforator anastomosis (the thigh perforator exchange) and illustrate its use in a subset of patients. This technique is relatively simple and rapid to perform with no vascular complications observed in our series.

High Above Knee Amputations for Femoral Osteosarcomas Treated with Free Microsurgical Tibial Reconstruction in the Pediatric Population.

Improvements in the management of pediatric sarcoma including imaging, neo- and adjuvant therapy, and surgical technique has enhanced long-term survival of patients. Pediatric patients diagnosed with a femoral osteosarcoma undergoing oncologic resection who are ineligible for limb preservation reconstruction or rotationplasty are offered an above knee amputation (AKA). Limb amputations in the skeletally immature patient poses particular problems specific to endosteal bone overgrowth and spiking. Approximately half of these patients undergo revision of their amputation site. Furthermore, a high AKA often requires a hip-based prosthesis, which can be uncomfortable leading to poorer outcomes and higher energy expenditures.We have completed four 'spare parts' microvascular free tibial transfers for pediatric patients diagnosed with femoral osteosarcoma who were treated with an AKA. Two of these patients are currently ambulatory with their prosthetic and have not required long-term revision of their amputation site. One patient demonstrated radiographic evidence of bony union four months post-operatively, but subsequently succumbed to chemotherapy-resistant metastases. The fourth patient is in the process of prosthetic fitting and rehabilitation.This is a novel technique and the first series describing both proximal and distal free microvascular tibial bone transfers as a reconstructive option for pediatric patients with femoral osteosarcomas. It is a reliable flap with possible variations in vascular anatomy. Furthermore, it offers multiple benefits including the prevention of bony spiking, AKA stump augmentation, and facilitation of appropriate prosthetic fitting improving functional outcomes and decreased energy expenditure. However, the soft tissue coverage must be well planned.

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region.

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety. This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05. Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common. The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Computed tomographic anatomic variations of the phrenicoabdominal veins in cats.

There are no published reports describing the anatomic variations of the phrenicoabdominal (PhAbd) veins in cats. The aim of this study was to evaluate the anatomic variations of the PhAbd veins in cats without adrenal disease. This is an anatomic study. Abdominal CT images of cats acquired from January 2021 to February 2023 were retrospectively reviewed. Inclusion criteria were the presence of pre- and postcontrast CT images of the abdomen and the absence of any abdominal diseases that compromise the left and right PhAbd veins visualization. A total of 128 cats were included. Three different vascular anatomic variations were found in the distal pericaval segment of the left phrenicoabdominal (LPhAbd) vein. In the first type, found in 65 cases (50.8%), the LPhAbd vein drained directly into the caudal vena cava. In the second type defined IIa, found in 25 cases (19.5%), the LPhAbd vein drained into the distal third of the left renal vein, less than 5mm from its opening into the caudal vena cava. In the third type defined IIb, found in 38 cases (29.7%), the LPhAbd vein drained into the distal third of the left renal vein, more than 5mm from its opening into the caudal vena cava. The right phrenicoabdominal vein had a consistent path and drained into the caudal vena cava in all cases. The knowledge of these vascular variations is expected to help the surgeon during adrenalectomy due to masses with vascular invasion in cats.

Captive Bolt Gun-Related Vascular Injury: A Single Center Experience.

This article investigates the clinical and radiological characteristics of captive bolt gun head injuries, a rare form of low-velocity penetrating brain injury. Eleven consecutive patients were included in the study. Vascular injuries and the rate of infection were systematically analyzed. Radiological findings reveal common bolt trajectories in the anterior cranial fossa, with identified risk factors for a poor outcome including trajectory crossing midline, hematocephalus, and paranasal sinus involvement. Only one patient had a good outcome. Despite meticulous microsurgical techniques, this study highlights often unfavorable clinical outcomes in captive bolt gun injuries, with vascular injury identified as a potential contributing risk factor for a poor outcome. Knowledge of variant vascular tree anatomy and corresponding vascular territory is important. To avoid potential vascular injuries, a complete removal of bone fragments was not always performed and it did not increase the rate of infection, challenging the conventional wisdom advocating for the complete removal of bone fragments. These findings contribute novel insights into captive bolt gun-related injuries, paving the way for further research.

Agenesis of the Celiac Trunk, A Rare Vascular Variant: A Case Report

Vascular anatomical variants of the abdomen are very frequent. Knowledge of these variants is of paramount importance in clinical practice, particularly in surgery, because of the related therapeutic implications. Agenesis of the celiac trunk is one of the rare anatomical variants of the abdominal aorta. A limited number of cases have been reported in the medical literature. We report a case of agenesis of the celiac trunk, with separate emergence of its three branches directly from the abdominal aorta, discovered incidentally during a computed tomography (CT)scan performed as part of extension assessment of gallbladder adenocarcinoma.

Evolution of cerebrovascular imaging and associated clinical findings in children with Alagille syndrome.

Alagille syndrome (ALGS) is a multisystem autosomal dominant disorder with highly variable expression. Intracranial arterial and venous anomalies have a reported prevalence of 30-40% and can increase the risk of stroke by 16%. Few reports document the frequency and evolution of cerebrovascular abnormalities (CVAs) in children with ALGS. We aimed to define the spectrum, frequency, and evolution of CVAs in a series of children with ALGS using magnetic resonance angiography (MRA). We conducted a single-center, retrospective study in a large tertiary pediatric hospital. CVAs were grouped into 4 categories: 1) Stenosis or narrowing; 2) Aneurysms and ectasias; 3) Tortuosity; and 4) Vascular anomalies and anatomical variants. Thirty-two children met the inclusion criteria. The median age at initial diagnosis was 6 (3.8-10.3) years. Thirteen (40%) had follow-up MRI at a mean of 55 (31.5-66) months. Eighteen (56%) had CVAs; the most frequent fell into group 1 (n = 12, 37.5%). CVAs were stable over time, except for one patient with Moyamoya arteriopathy (MMA). One patient developed a transient ischemic attack secondary to an embolic event. Three (9.3%) had microhemorrhages at the initial diagnosis secondary to Tetralogy of Fallot. Another patient had recurrent subdural hematomas of unknown cause. CVAs were stable except in the presence of MMA. Vascular strokes, which are reported in older patients with ALGS, were not a common feature in children under 16 years of age, either at presentation or over the 31.5-66 month follow-up period.

Posterior Belly of Digastric Muscle is not Always an Intern's Friend, During Neck Dissection.

Among the various anatomical landmarks during neck dissection, digastric muscle is one of the most important. It is well known that all important blood vessels in neck lies deep to digastric. Thus, it acts as a safety landmark during neck dissection. In this article we describe a variation in vascular anatomy with relation to posterior belly of digastric that has not been reported so far during live surgery. Surgeon performing neck dissection should have a detailed knowledge of anatomy and infrequent anatomical variation. The knowledge of current anatomical variation will avoid torrential bleed during neck dissection and preserve the artery for vascular related procedures.

Vascular injury risk stratification for lateral lumbar interbody fusion (LLIF) at L4-L5: a morphometric study using magnetic resonance imaging.

Proper vascular injury risk stratification (VIRS) methods for L4-L5 lateral lumbar interbody fusion (LLIF) surgery have not been well-described. The objective of this study was to propose a novel VIRS method for L4-L5 LLIF surgery via the transpsoas approach. Axial magnetic resonance imaging (MRI) of adult patients were obtained and analyzed. The VIRS scores were assessed using anterior disc line to posterior vessel wall distance, the disc vessel angle (DVA), and the disc edge to vessel distance at the level of L4-L5 disc space. Ninety-one consecutive adult patients were included in the study. The right common iliac vein (CIV) had a high risk of injury with both right- and left-sided approaches. The left CIV had a moderate risk with a left-sided approach when the iliocaval confluence was above the L4-L5 disc space but had a high risk when the confluence was at the L4-L5 disc space. The left CIV had a high risk with a right-sided approach when the confluence was above the L4-L5 disc space but had a moderate risk when the confluence was at the L4-L5 disc space. The inferior vena cava (IVC) had a high risk with both right- and left-sided approaches. The aorta had a moderate risk regardless of the right or left-sided approaches. The left common iliac artery (CIA) had a moderate risk with a right-sided approach and a low risk with a left-sided approach. The right CIA had a low risk with both right- and left-sided approaches. There are significant vascular anatomic variations at the L4-L5 disc level and a proper VIRS can be performed utilizing a combination of anterior disc line to posterior vessel wall distance, DVA, and disc edge to vessel distance, on the axial MRI.

Vascular and Urinary Tract Anatomic Variants Relevant to Para-Aortic Lymphadenectomy in Women with Gynecological Cancers.

Para-aortic lymphadenectomy is an essential part of gynecologic oncologic surgical treatment. The surgeon should be aware of the complex usual anatomy and its common variants. Between January 2021 and May 2023, 58 women underwent para-aortic lymphadenectomy for gynecologic malignancies. Vascular and urinary tract anatomic variants were retrospectively reviewed from the prospective institutional database and results were compared with preoperative contrast-enhanced abdominal CT. Of these 58 women, 47 women had no vascular or urinary tract variants. One woman had a double inferior vena cava, two patients were found to have a retro-aortic left renal vein, four had accessory renal arteries, two had a double left ureter, one had a ptotic kidney in the iliac fossa, and one patient had bilateral kidney malrotation. Anatomic variants in the preoperative CT were described by a radiologist in only two patients, and additional vascular and urinary tract variants were found incidentally at the time of surgery. Acknowledgment of vascular and urinary tract variants is helpful for the surgeon to establish an appropriate surgical plan and to avoid iatrogenic surgical trauma.

Anatomical variations in living donors for liver transplantation-prevalence and relationship.

Living donor liver transplantation (LDLT) is a widely accepted option to address the lack of a deceased liver program for transplantation. Understanding vascular and biliary anatomy and their variants is crucial for successful and safe graft harvesting. Anatomic variations are common, particularly in the right hepatic lobe. To provide evidence for screening potential liver transplant donors, the presence of vascular and biliary anatomic variations in Pakistan's preoperative assessment of transplantation donor candidates was explored. This retrospective cross-sectional study evaluated the hepatic artery, portal vein, hepatic vein, and biliary variations in living liver donors. The study included 400 living liver donors; data were collected from March 2019 to March 2023. We used a CT scan and MRCP to assess the anatomical variations. The study examined 400 liver donors aged 18 to 53 years. Conventional arterial anatomy was the most common (65.8%), followed by replaced right hepatic artery (16%) and replaced left hepatic artery (10.8%). Conventional type 1 biliary anatomy was seen in 65.8% of cases. The dominant right hepatic vein was found in 13.3% of donors. There was a significant association between the prevalence of variant portal venous anatomy with variant biliary anatomy. Variations of the hepatic arterial, portal venous, and biliary systems are frequent and should be carefully evaluated while selecting a suitable living donor. A strong relationship between variant portal venous and biliary anatomy was found. These findings can aid in selecting suitable candidates and improving surgical planning for liver transplantation.

A more radical perspective on surgical approach and outcomes in pancreatic cancer-a narrative review.

Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical aspects for pancreaticoduodenectomy (PD), distal and total pancreatectomy (TP), incorporating lessons from both the western and eastern visions in treating pancreatic cancer. We conducted an extensive literature review through PubMed, prioritizing papers published in the last 5 years, but older emblematic papers were also included. We included articles that explored the treatment of pancreatic adenocarcinoma, with focus on the surgical aspect and strategies to improve outcomes. References of selected articles were also reviewed to identify any missed studies. Only papers in English were included. As evidence continues to build, it is clear that both systemic and surgical therapies have a fundamental and complementary role. State of art surgical treatment encompasses complete mesopancreas excision for radical lymphadenectomy. Preoperative planning of dissection planes, extensive knowledge of vascular anatomic variations, oncological principles and expertise for vascular resections are mandatory to perform a more radical operation, in pursuit of improved outcomes. Based on current data, patient selection remains key and a more radical surgical approach brings more accomplishing results bringing as to believe that more is better.

Drainage pattern of the splenic flexure vein and its accompanying arteries using three-dimensional computed tomography angiography: a single-centre study of 600 patients.

The splenic flexure has variable vascular anatomy, and the details of the venous forms are not known. In this study, we report the flow pattern of the splenic flexure vein (SFV) and the positional relationship between the SFV and arteries such as the accessory middle colic artery (AMCA). This was a single-centre study using preoperative enhanced CT colonography images of 600 colorectal surgery patients. CT images were reconstructed into 3D angiography. SFV was defined as a vein flowing centrally from the marginal vein of the splenic flexure visible on CT. AMCA was defined as the artery feeding the left side of the transverse colon, separate from the left branch of the middle colic artery. The SFV returned to the inferior mesenteric vein (IMV) in 494 cases (82.3%), the superior mesenteric vein in 51 cases (8.5%) and the splenic vein in seven cases (1.2%). The AMCA was present in 244 cases (40.7%). The AMCA branched from the superior mesenteric artery or its branches in 227 cases (93.0% of cases with existing AMCA). In the 552 cases in which the SFV returned to the IMV, superior mesenteric vein or splenic vein, the left colic artery was the most frequent artery accompanying the SFV (42.2%), followed by the AMCA (38.1%) and the left branch of the middle colic artery (14.3%). The most common flow pattern of the vein in the splenic flexure is from the SFV to IMV. The SFV is frequently accompanied by the left colic artery or AMCA.

RADIOLOGICAL EVALUATION OF PEDIATRIC SENSORINEURAL HEARING LOSS AT A TERTIARY CARE CENTER IN CENTRAL INDIA

Objective: Hearing dysfunction is the most common sensory deficit in children. If hearing is lost, especially in children's, it may have a huge impact on life, interfering with the acquisition of spoken language and social development. It is therefore important to detect any abnormalities at an early age. Patients with complaint of inability to hear since birth attending ENT OPD, M.Y.H Hospital, Indore and patients referred to M.Y.H hospital from district hospitals with inability to hear since birth were evaluated clinically and audiometry was done. Patients with SNHL fulfilling the inclusion criteria were considered and their radiological evaluation was done. High resolution computed tomography scan (HRCT) of temporal bone were used in radiological evaluation of patients with congenital sensorineural. SUBJECTS AND METHODS: The study was conducted at a tertiary care centre Maharaja Yashwantrao Holkar (MYH) hospital and Mahatma Gandhi Memorial Medical College (MGMMC), Indore in the Department of otorhinolaryngology and head &amp; neck surgery. Cases with hearing loss from 1 to 16 years of age were selected. A detailed medical history with primary focus on inability to hear was obtained with emphasis on previous hospital stays, developmental delay, maternal history, family history. Complete ENT examination was done. Our study included a total 30 children. All chil Results: dren were between 1-16 years of age with sensorineural hearing loss. Majority 11(36.67%) of the participated in the study were between 5-8 years of age. Cochlear anomaly was found in 03(10%) patients. Cochlea was found normal in 27(90%) on both the ears, 03(10%) child had hypoplastic cochlea bilaterally, none were with aplastic cochlea. Vestibular anomaly was seen normal in 28(93.33%) patients on bilateral side. 02(6.67%) patients were present with dysplastic vestibule. SSC was found dysplastic/malformed in 04(13.33%) patients who had dysplastic/malformed semicircular canal. Conclusion: The selection of candidates for hearing aid trials and cochlear implantation requires consideration of a variety of clinical, audiological and radiological factors. Imaging is a fundamental part of the preoperative workup, it provides the surgeon with details which will lead him to a successful cochlear implantation with no or minimal complications. HRCT temporal bone provided us the information about the presence of various inner ear malformations including cochlea, vestibule, SCC, IAC. Mastoid, pneumatization, variations in vascular anatomy which included forward lying sigmoid sinus and high riding jugular bulb. All these findings are important for a detection of cause of SNHL in patients.

Variant anatomy of non-recurrent laryngeal nerve: when and how should it be taught in surgical residency?

While the performance of a thyroidectomy is generally associated with a low risk of injury to the recurrent laryngeal nerve (RLN), the presence of a non-recurrent nerve (NRLN) increases the risk of this complication. Generally, the intraoperative detection via visual appreciation of variant anatomy of the RLN has been regarded as poor, possibly due to a lack of knowledge of both the normal and aberrant anatomy of the RLN. Articles for the review were searched through PubMed using the search terms and their combinations: "non-recurrent laryngeal nerve," "thyroidectomy," "injury," "palsy," "variant anatomy," and "residency," from January 1, 2000, to December 2022. Papers considered for the review were the articles published in English, with additional classic and articles of surgical importance retrieved from the reference list of papers. Only papers relevant to the scope of the review were considered for this review. The NRLN has been found to be associated with concurrent vascular abnormalities, such as the presence of an aberrant right subclavian artery (ARSA) or an arteria lusoria originating from the aortic arch. However, it seems that both the normal as well as aberrant anatomy of the RLN is currently not emphasized enough during postgraduate surgical training. With the increased use of intraoperative neuromonitoring (IONM), detection of NRLN has become possible through appropriate neural mapping during thyroid surgery, besides other pointers such as visualization during surgery, computerised tomography, and duplex ultrasound scans to visualize the variant vascular anatomy. There is also a possible role for cadaveric courses, either during medical school or in a post-graduate setting-adapted to the student's level to teach the variant anatomy. With the development of newer techniques such as artificial intelligence, there are potential new options for teaching and training anatomy in the near future. Adequate knowledge of the normal and aberrant anatomy of the RLN remains essential for the best outcomes in thyroid surgery, even in the era of the IONM. Moving forward, the knowledge of (aberrant) anatomy should be made an integral part of the core competencies of both medical students and surgical trainees. It is imperative that leaders of the different field work closely together to combine their knowledge towards providing their trainees with the best possible training options.

Agénésie du tronc cœliaque : à propos d'un cas

Vascular anatomical variants in general, and of the celiac trunk (TC) in particular, are rarely reported in the literature because they are generally asymptomatic and detected incidentally by imaging examinations performed for other causes. We report a case of agenesis of the celiac trunk, with separate birth of its three branches directly from the abdominal aorta, discovered fortuitously during a CT scan performed as part of the extension assessment of colon adenocarcinoma in a woman. initially asymptomatic.

An Easy Way to Harvest a Superthin SCIP Flap with Long Pedicle: Reappraisal of the Inferolateral Branches of the SCIA.

Despite being the first free flap used in reconstructive surgery, the groin flap slowly fell out of fashion because of its short pedicle length, small vessel diameter, variable vascular anatomy, and bulkiness. Over the years, the authors have found that perforators consistently exist inferolateral to the deep branch of the superficial circumflex iliac artery (SCIA), forming an F configuration with the main branch. The authors propose a new type of superficial circumflex iliac artery perforator (SCIP) flap design based on the perforators derived from these inferolateral branches of the SCIA. These perforators have the advantage of anatomic consistency and can be easily found by making an exploratory incision 2 cm caudal to the inguinal ligament. The perforators of the inferolateral branches extend directly into the dermal plexus, and thus can yield superthin flaps without microdissection defatting. Retrograde dissection allows the surgeon to elongate the pedicle to include a section or full length of the SCIA as needed and involving minimal muscle dissection. SCIP flaps harvested based on the perforators of the inferolateral branches of the SCIA were used successfully for six head and neck reconstructions and two trunk reconstructions with no major complications, including flap loss or lymphedema. The best indications for SCIP flaps based on the inferolateral branches of the SCIA are superficial soft-tissue defects that do not require much volume replacement.