Duplication of the Artery to the Cystic Duct: A Case Report of a Rare Anatomical Variation with Surgical Significance.

Anatomical variations of the cystic artery are frequently documented, but variations of the artery to the cystic duct are extremely uncommon. We report a rare duplication of the artery to the cystic duct, revealed during laparoscopic cholecystectomy on an 18-year-old Caucasian female treated for gallstone disease. Both arterial branches were meticulously and carefully retracted and cauterized to avoid bleeding and subsequent postoperative complications. To our knowledge, this is the first reported case of an artery to the cystic duct duplication. The presence of congenital variations of the artery to the cystic duct encumbers surgical maneuvers and increases the potentiality of intraoperative injury and hemorrhage.

Surgical administration of multiple glomus tumors in uncommon anatomic regions in a 17-year-old female. A rare case report.

Glomus tumor (GT) constitutes a rare, benign, soft-tissue tumor emerging from neuro-myo-arterial glomus bodies. Due to its rarity, and absence of typical symptoms, GT is usually misdiagnosed, with a potential risk of rupture and infection, or even malignant transformation. The present manuscript reports a rare case of a 17-year-old young woman with multiple GTs in her lower back, breach and left thigh that was surgically treated. The manuscript aims to highlight the importance of prompt diagnosis and surgical treatment of this peculiar tumor in young patients and raise surgeons' awareness.

Intestinal necrosis and sigmoid colon obstruction due to bilateral strangulated femoral hernia in a male: a rare surgical and anatomic case report.

Bilateral femoral hernia is a peculiar clinical condition, with female predominance, with only a few cases reported in the literature. There are only two cases of bilateral strangulated femoral hernias, and these occur solely in females. To our knowledge, in the present manuscript, a bilateral strangulated femoral hernia in a male patient is reported for the first time. A 68-year-old male proceeded to the emergency department of our institution with symptoms of bowel obstruction. Abdominal computed tomography, magnetic resonance imaging and subsequent emergency laparotomy revealed obstruction of the sigmoid colon and simultaneous necrosis of several loops of the small intestine due to bilateral strangulated femoral hernia. The operation was uneventful. Despite the scarcity of this clinical condition, surgeons' awareness is fundamental, in addition to deep knowledge of the pathology and the anatomy of femoral hernias, in order to diagnose and treat adequately strangulated and incarcerated femoral hernias.

Liposarcoma of the pelvic fossa masquerading as hematoma: a rare case report and its surgical management.

Liposarcomas constitute rare malignant tumors of the soft tissue, with wide anatomical distribution. The prompt diagnosis of a liposarcoma is extremely challenging since these tumors tend to remain asymptomatic, until they grow enough to displace adjacent anatomical structures. In the presented case, a 55-year-old Caucasian male proceeded to our institution complaining about irreducible swelling of the right iliac fossa and constant discomfort, over the course of a year. His medical history revealed injury of the right groin and pelvis a year ago. The diagnosis was ilioinguinal liposarcoma masquerading as hematoma, due to the previous injury. The patient underwent primary complete tumor resection, and the operation was uneventful. The essential diagnostic and surgical steps for the management of a liposarcoma, mimicking a hematoma are meticulously described.

Anomalous anatomic trajectory of the superior thyroid artery encountered during thyroidectomy. A rare case report.

Superior thyroid artery (STA), which is one of the primary arteries supplying to the thyroid gland, constitutes a severe consideration of both surgeons and interventional radiologists. Knowledge of the origin, the trajectory, the branching patterns and the anatomic aberrations of STA are of paramount clinical significance, due to its proximity to the external branch of the superior laryngeal nerve and the potentiality of accidental hemorrhage. The present manuscript reports for the first time the anomalous trajectory of the left STA, coursing superficially, through the left sternothyroid muscle and underlines the clinical significance of such aberrations.

Standard and Variable Key Anatomical Structures for Safe Surgical Repair of Bochdalek Hernia: A Rare Case Series.

Bochdalek hernia (BH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the thoracic viscera. This type of hernia is rare in adults, usually asymptomatic and may be diagnosed incidentally in a routine chest X-ray. The aim of the present retrospective study was to highlight the standard and important anatomical structures that are crucial to safe surgical repair of BH during laparotomy and thoracotomy by the placement of mesh graft, along with a short review of the existing evidence. Records from 2005 to 2017 were reviewed to identify the patients with adult BH who underwent mesh repair through thoracotomy or laparotomy and evaluate the possible complications and results. Six patients were operated for adult BH with the above-mentioned techniques. Four underwent laparotomy and two were treated through thoracotomy. Mild fever was reported only in one patient. There was significant improvement in the symptoms of all patients and no recurrence was reported in the subsequent follow-up period. Surgical treatment is strongly indicated for both symptomatic and asymptomatic patients. Surgeons' in-depth knowledge of the anatomy of the diaphragm will ensure better outcomes for the patients.

Erratum: The clavipectoral fascia as the unique anatomical criteria for distinguishing breast parenchymal lesions from axillary lymph node metastasis.

[This corrects the article DOI: 10.1093/jscr/rjz135.].

Anatomical variation of the trajectory of the brachiocephalic artery encountered during parathyroid adenoma excision. A rare case report and a surgical challenge.

INTRODUCTION: The brachiocephalic trunk (BCT), also known as the "anonymous artery" constitutes the first branch of the aortic arch that bifurcates at the level of the right sternoclavicular joint into the RCCA and the RSA. Anatomical variations of the origin and the trajectory of BCT are of vital clinical significance since they constitute major risk-factors of hemorrhage when performing tracheotomy, surgeries at the anatomic area of the neck as in the presented case. PRESENTATION OF CASE: A 64-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized posterior to the right thyroid lobe. During the operation, surgeons incidentally detected anterior to the trachea aberrant trajectory of the BCT. The operation was uneventful. A meticulous review of the literature was conducted as well. DISCUSSION: Anatomical anomalies of the origin and the trajectory of BCT are vaguely described in the literature. However, these anatomic variations constitute major risk-factors of accidental bleeding and subsequent complications when performing surgeries of the thyroid and parathyroid glands, tracheotomy and invasive radiological interventions. CONCLUSION: Deep knowledge of such variations of the trajectory of the BCT in addition to detailed exposure of the operative field constitute the cornerstone in order surgeons to perform a safe intervention.

The clavipectoral fascia as the unique anatomical criteria for distinguishing breast parenchymal lesions from axillary lymph node metastasis.

Diagnosing primary breast tumors of the axillary tail of Spence may be extremely challenging, since several lesions may be located in the axillary fossa. In the presented case, a 54-year-old post-menopausal Caucasian female patient presented to our institution complaining about a lump in her left axilla. The preoperative imaging modalities could not clarify whether the tumor is part of the tail of Spence or metastasis of the axillary lymph nodes. The diagnosis of primary adenocarcinoma of the axillary tail of Spence was made during a quadrantectomy of the left breast after the clavipectoral fascia, which constitutes the sole anatomical boundary between breast and axilla, was identified.

An anatomic aberration and a surgical challenge: Mediastinal parathyroid adenoma anterior the pericardium. A case report.

INTRODUCTION: Ectopic parathyroid glands occur in 6-16% of cases of PHPT and they constitute a potential cause of failed primary surgical therapy. In particular, aberrant adenomas located deeper in the mediastinum, as in the presented case, remain a severe challenge for the surgeons. PRESENTATION OF CASE: A 54-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized in the lower anterior mediastinum, on the left of the median line. A mid-sternal thoracotomy was performed and the aberrant adenoma was finally detected anterior to the pericardium and the left pericardiophrenic vessels and the left phrenic nerve. The operation was uneventful. A meticulous review of the literature was conducted as well. DISCUSSION: Single parathyroid adenomas are the key culprits of PHPT. Anatomic aberrations of the location of the parathyroid glands and their adenomas are more common than described in the literature and there are possible anatomic aberrations that have not been described yet. All these anatomic variations constitute major risk-factors of thoracic bleeding and of nerve injury. CONCLUSION: Detailed preoperative detection in addition to meticulous exposure of the operative field are fundamental in order to perform a safe adenoma excision without harmful impacts to the patient.

WITHDRAWN: An anatomic aberration and a surgical challenge: Mediastinal parathyroid adenoma anterior the pericardium. A case report.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in "International Journal of Surgery Case Reports, 57C (2019) 106­109", https://doi.org/10.1016/j.ijscr.2019.03.014. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Massive Localized Lymphedema: Two Rare Case Reports of this Peculiar Entity and Anatomic Distortion.

INTRODUCTION: Massive localized lymphedema (MLL), also called pseudosarcoma in the literature, constitutes a rare benign clinical disorder presenting in obese patients and characterized by chronic accumulation of lymph and adipose tissue due to lymphatic flow obstruction. PRESENTATION OF CASE: A 43-year-old, morbidly obese white woman proceeded to our institution with extended lymphedema. In addition, a 54-year-old white man sought medical advice for the same clinical issue. Surgical excision of the soft tissue mass was performed in both cases so that the patients could regain mobility of their limbs. The operation was uneventful. The histopathologic analysis asserted the diagnosis of MLL. A meticulous review of the literature was conducted as well. DISCUSSION: MLL is a scarce, non-malignant clinical entity that may mimic an abundance of soft tissue tumors. Patients with MLL are typically obese females with body mass index (BMI) > 40 kg/m2 who present with non-specific symptoms. The diagnosis of MLL is challenging, and its etiology and treatment are not completely elucidated. CONCLUSION: Surgeons' deep knowledge regarding this peculiar clinical disorder is the cornerstone for the establishment of a correct diagnosis and warrants the adequate treatment, in addition to the elimination of the potentiality of malignant transformation of MLL to angiosarcoma or liposarcoma and of probable recurrence of MLL.

The Accessory Soleus Muscle: A Narrative Review of the Literature.

PURPOSE: Although the accessory soleus muscle is a rare supernumerary muscle of the leg, its presence has been well discussed in the literature. This rare anatomic variation has been described mainly in the anatomic, surgical, and radiology literature. Awareness of the muscle's presence and its clinical presentation can help with diagnosis without surgical exploration. This narrative review summarizes the available data describing the anatomy, clinical presentation, diagnosis, associated pathologies, and treatment options of this accessory muscle. METHODS: A literature review was performed to provide a comprehensive report of the existing data regarding the accessory soleus muscle. PubMed, Heal Link, and Google Scholar were searched for articles in English reporting on the accessory soleus muscle. The search was conducted using the following key words: "soleus muscle" and "accessory soleus muscle". PubMed was searched primarily, and then cross-referenced articles were found via Heal Link and Google Scholar. Results from non-English studies were excluded. RESULTS: A total of 148 articles were reviewed. The majority of the articles was composed of case reports along with a review of the literature. After the initial screening, 33 irrelevant studies, 47 duplicates, and 9 non-English articles were excluded; thus, 59 studies were eligible for analysis. CONCLUSION: Although the accessory soleus muscle is a rare anatomic variation, many cases have been reported in the literature. Nonetheless, the results reported in this literature review are still inconclusive regarding why some patients are symptomatic and others are not, and the recommendation of therapy protocols. Recognizing this anomaly is important in deciding the right diagnosis and planning the appropriate treatment. However, further research is needed to investigate the symptoms' presentations and propose specific treatment protocols.

Safe Popliteal Node Dissection and Utility of Key Anatomical Structures: A Rare Case Series.

Metastasis in popliteal nodes is an extremely rare clinical condition that is scarcely reported in the literature, and popliteal node dissection is an infrequently performed surgical procedure. During the two decades of 2000-2020, 26 patients came to our institution for popliteal node dissection due to metastasis from the primary region to popliteal fossa lymph nodes. We report here that with lymphoscintigraphy, popliteal node dissection is an adequate therapeutic procedure in cases of metastasis to popliteal fossa from acral primary tumors. However, because the frequency of this surgical procedure is typically low, surgeons are often inadequately trained in the proper approach using key anatomical structures to guide them during popliteal node removal. We describe a stepwise surgical approach in the hopes of increasing the surgeon's knowledge, which is pivotal and fundamental for performing successful popliteal lymphadenectomy without hazardous impacts to the patient.

Complete unilateral ureteral duplication encountered during intersphincteric resection for low rectal cancer.

Complete duplication of ureters is a very rare clinical entity that may either be asymptomatic or present with a variety of clinical findings. In the presented case a 51-year-old Caucasian female underwent an intersphincteric resection for low rectal cancer. Intraoperatively, during the standard bilateral recognition and mobilization of the ureters, complete unilateral duplication of the left ureter was incidentally detected, deriving from a single renal parenchyma. Such a congenital abnormality though constitutes a major risk-factor of accidental ureteral injury during operations including pelvis. Conclusively, meticulous exposure of both ureters combined with surgeons' unceasing awareness constitute the cornerstone of a safe operation.

Anatomic variation of the relation between the inferior mesenteric artery and the bifurcation point of abdominal aorta during lower anterior resection: A rare case report.

INTRODUCTION: Identification and ligation of the inferior mesenteric artery (IMA) is a crucial surgical step when performing lower anterior resection (LAR) for rectal cancer. Anatomic variations of the relation between the IMA and the bifurcation point of abdominal aorta (AA) encumber surgical maneuvers and are of great clinical importance. PRESENTATION OF CASE: An unusual anatomic variation of the relation between IMA and the bifurcation point of AA was unexpectedly detected during LAR to a 69-year-old Caucasian female patient. The operation was uneventful. A meticulous review of the recent literature was conducted as well. DISCUSSION: Variations of the mesenteric vascular supply are mainly identified incidentally, during the operation. In particular, variations of IMA are extremely uncommon in the literature. However, such kind of congenital variations, are not as rare as considered and their presence encumbers surgical maneuvers and increases the potentiality of intraoperative injury and hemorrhage. CONCLUSION: Surgeons' deep knowledge and unceasing awareness concerning probable anatomic variations of the relation between the IMA and AA, combined with detailed exposure of the operative field and of the relationship between these adjacent arteries constitute the cornerstone of a safe operation.

Anomalous course of the sigmoid colon and the mesosigmoid encountered during colectomy. A case report of a redundant loop of sigmoid colon.

Introduction Sigmoid colon constitutes a part of the large intestine that presents several congenital anatomic variations. In particular, the presence of a redundant loop of sigmoid colon is of tremendous importance for surgeons, obstetricians and radiologists, since it is closely related to multiple pathological conditions and functional implications of the neighboring anatomical structures. PRESENTATION OF CASE: An unusual anatomic variation in position and length of the sigmoid colon and its mesocolon was unexpectedly detected during right hemicolectomy to a 67-year-old Caucasian male patient due to colon cancer. The operation was uneventful. A meticulous review of the literature was conducted as well. DISCUSSION: A redundant loop of sigmoid colon may go unnoticed or it might lead to urinary, digestive and vascular complications. Its presence is associated with acute and chronic pathological conditions, sigmoid volvulus and serious confusions in radiological diagnosis and instrumentation. CONCLUSION: Surgeons' thorough knowledge concerning this rare anatomic variation is fundamental and crucial in order to establish a correct diagnosis and assert the appropriate management when performing operations including pelvis and abdomen.

Abnormal distance of the extralaryngeal bifurcation point of the recurrent laryngeal nerve from the cricothyroid joint.

The extralaryngeal bifurcation point of the recurrent laryngeal nerve (RLN) is typically located in a mean distance of 0-2 cm from the cricothyroid joint (CTJ). In the presented case though, the left RLN was unexpectedly identified bifurcating in a mean distance of 7 cm from the left CTJ in a young woman with multinodular goiter during total thyroidectomy. The RLN was carefully exposed throughout its course for the avoidance of iatrogenic injury of the nerval structure. The operation was uneventful. The present manuscript aims to highlight a scarce anatomic variation and its implications for thyroidectomy. Rare anatomic variations of the RLN such as the presented one encumber thyroid surgery and represent a severe risk factor of RLN injury. Meticulous operative technique combined with surgeons' perpetual awareness concerning this peculiar anatomical aberration leads to an injury-free thyroid surgery.

Anomalous origin of the right colic artery from the right gastroepiploic artery during complete mesocolic excision: a rare case report.

Complete mesocolic excision (CME) is a standardized surgical procedure for colonic cancer that requires ample knowledge of the anatomical patterns of the colic arteries. Variations of the colic vessels encumber both surgical and endovascular techniques. In the presented case below, the right colic artery was incidentally detected emerging from the right gastroepiploic artery, during CME. Surgeons should be always aware of this variation in order to perform safe abdominal surgeries and sufficient resection of the regional lymph nodes with a view to minimizing the probability of recurrence of disease when encountering colonic cancer.