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Highlights • Ectopic parathyroid adenomas located deeper in the mediastinum remain a surgical challenge. • Their incidence reaches up to 20% of the general population and they tend to constitute a severe cause of failed primary surgery for PHPT. • Such aberrations seem to be more common than described in the literature and there are possible anatomic aberrations that have not been described yet. • Preoperative detection of the mediastinal parathyroid adenoma and detailed exposure of the operative field are essential for a safe mid-sternal thoracotomy., 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.

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.

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.

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.

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.

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.

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.

Highlights • BCT may present anatomical variations concerning its origin and its trajectory. • Preoperative observation of these anatomical variations has vital clinical and surgical importance, since they constitute risk-factors of severe bleeding. • Fundamentals to avoid iatrogenic injury are: (1) exposure of the trajectory and the origin of BCT, since it is quite evident that probable novel anatomic variations could be unexpectedly detected during the operation (2) good haemostasis and (3) preoperative utilization of diagnostic ultrasound., 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.

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.

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.

Highlights • The facial nerve (FN) and the retromandibular vein (RMV) are anatomical structures in close proximity. Anatomic variations of their relationship complicate parotid surgery and increase the potentiality of nerve injury or bleeding. • The true prevalence of such kind of variations seems to be underestimated, since the literature is restricted. • Novel variations of the relationship of the FN with the RMV are probable. Therefore, surgeons’ knowledge and perpetual awareness are fundamental and essential in order to perform safe parotid surgery., Introduction Identification and preservation of the facial nerve (FN) is a major challenge when performing parotidectomy. Anatomic variations of the relation between the FN and the retromandibular vein (RMV) pose a high risk of nerve injury and bleeding during the operation. Presentation of case An unusual anatomic variation of the relation between the FN and the RMV was unexpectedly detected during superficial parotidectomy. The operation was uneventful. A meticulous review of the recent literature was conducted as well. Discussion Variations of the relation between the FN and the RMV are mainly identified during the operation, since when performing parotidectomy, surgeons typically detect all the FN branches by locating the RMV. Such kind of variations, are not as rare as considered and their presence complicates parotid surgery and increases the potentiality of nerve injury and hemorrhage. Conclusion Surgeons’ deep knowledge and perpetual awareness concerning the probable anatomic variations of the relation between the FN and the RMV combined with detailed exposure of the operative field and of the relationship between these adjacent anatomical structures lead to safe parotid surgery.

Highlights • Aberrant subvesical bile ducts are a rare anatomical variation defined as a network of bile ducts located in the peri-hepatic tissue of the gallbladder fossa. • Their injury is almost inevitable and it leads to bile leakage, which is a life-threatening complication of laparoscopic cholecystectomy. • Meticulous operative technique and detailed exposure of the operative field is the cornerstone of a safe laparoscopic cholecystectomy, when surgeons encounter this rare anatomical variation., Introduction Aberrant subvesical bile ducts are a scarce anatomical variation, consisted by a network of bile ducts located in the peri-hepatic capsule of the gallbladder fossa. These rare ducts are usually discovered intraoperatively and their presence poses the risk of bile injury and clinically significant bile leak. Presentation of case Aberrant subvesical bile ducts were unexpectedly identified in a young woman during laparoscopic cholecystectomy. These three ducts were clipped carefully for avoidance of bile duct injury and subsequent bile leak. The operation was uneventful. A meticulous review of the recent literature was conducted as well. Discussion This unusual anatomical variation of the biliary tract is mainly discovered during the operation. Thus, surgical injury of these ducts is nearly inevitable and it provokes the severe complication of bile leak. Bile injury represents the most crucial and life-threatening postoperative complication of cholecystectomies. Surgeons in the right upper quadrant of the abdomen should be constantly aware of this rare anatomical variation. Conclusion Aberrant subvesical bile ducts are associated with a high risk of surgical bile duct injury. Nevertheless, meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to a safe laparoscopic cholecystectomy.

Hemorrhoids are a common anal disorder which affects both men and women of all ages. One out of ten patients with hemorrhoidal disease, requires surgical treatment. Unfortunately though, hemorrhoidectomy is closely related to complications that can be present early or late postoperatively. In the present manuscript, the safe surgical technique which emphasizes to the identification of the key anatomical structure of the ligament of Parks (Trietz's muscle) is adequately described. A total of 200 patients with grades III and IV hemorrhoids, underwent Milligan-Morgan or Ferguson's hemorrhoidectomy. The mucosal ligament of Parks was identified to all patients and was used as a key anatomical structure through the excision of the hemorrhoids. Its identification guides surgeons during the operation and reduces the major problem of postoperative complications. Finally, since the mucosal ligament of Parks represents a constantly identifiable landmark, it allows simple and reliable identification of the internal sphincter muscle and minimizes the probability of postoperative complications., Highlights • The Parks ligament (Trietz muscle) tethers the dentate line of the anal canal with the internal sphincter. • Identification of the Parks ligament guides surgeons to the detection and preservation of internal sphincter through hemorrhoidectomy. • Finally, the identification of the key-anatomical structure of the Parks ligament reduces postoperative complications of hemorrhoidectomy.

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.

Highlights • Anatomic variations of the origin of IMA and of its relationship with the AA are of paramount clinical importance as regards to diagnosis and surgical treatment. • Such variations might encumber high ligation of the IMA during surgery for rectal cancer, with subsequent implications or may pose a major risk factor of accidental injury and hemorrhage. • Such anatomic variations of the origin of the IMA and its relationship with AA, may be actually more common, than described in the literature., 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.

Highlights • LSG is a peculiar anatomical variation that is difficult to be identified preoperatively. • LSG is associated with anatomical anomalies that may lead to intra-operative injuries. • Safe laparoscopic cholecystectomy is feasible by placing the patient to left-side up position for better exposure of the operative field., Introduction True Left-sided gallbladder (LSG) is a rare anatomical variation with a prevalence of 0.3%. Mainly discovered during the operation, its surgical approach in the laparoscopic setting may be challenging even for an experienced surgeon. Presentation of case LSG was unexpectedly discovered in a young man during laparoscopic cholecystectomy. There were no pre-operative indications of this sinistroposition. The laparoscopic cholecystectomy was performed with minor surgical modifications and it was uneventful. A meticulous review of recent literature about LSGs was conducted as well. Discussion LSG is a scarce anatomical aberration that is difficultly identified pre-operatively. Surgeons should be aware of this aberration and of its accompanying anatomical variations in order to perform a safe laparoscopic cholecystectomy. Conclusion Surgeons, by placing the patient to left-side up position, are able to expose the Calot’s triangle and possible accompanying anatomical anomalies and thus perform a safe laparoscopic cholecystectomy without difficult surgical modifications.

Highlights • A redundant sigmoid colon is defined as one that is too long to fit into its owner’s body without undergoing reduplication. • It is associated with acute and chronic pathological conditions, sigmoid volvulus and serious confusions in radiological diagnosis and instrumentation of imaging procedures. • Surgeons, obstetricians and radiologists ought to be aware of this variation and to emphasize to the correlation between gross and clinical anatomy, since their awareness determines the outcomes of an operation and the accurate radiographic diagnosis., 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.

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.

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.

Highlights • Differential diagnosis of LPD from leiomyosarcoma or benign metastasizing leiomyoma remains difficult. • Ample history of the patient, clinical evaluation, preoperative guided FNA and histopathologic analysis of the FNA tissue and of the tumor resection are essential for differential diagnosis. • Prompt diagnosis of LPD is crucial because, although benign in nature, LPD may degenerate into malignancy., Introduction Leiomyomatosis peritonealis disseminata (LPD) is a peculiar benign clinical disorder characterized by proliferation of peritoneal and subperitoneal nodules. LPD is a difficultly diagnosed benign disease that rarely degenerates into malignancy. Presentation of case A 40-year-old Caucasian female with vaginal bleeding proceeded to our institution for elective excision of abdominal and pelvic masses which were firstly considered as leiomyosarcomas. The histologic diagnosis of the mass lesions revealed smooth muscle benign cells. This is the first case of LPD reported in Greece. A meticulous review of the literature was conducted as well. Discussion The differential diagnosis of LPD is difficult due to its clinical resemblance with peritoneal carcinomatosis or metastatic lesions and with benign metastasizing leiomyoma (BML) as well. Etiological factors, pathophysiology and clinical manifestations which lead to a safe diagnosis of LPD are adequately described. Conclusion Surgeons’ thorough knowledge concerning this rare clinical condition is fundamental and crucial in order to establish a correct diagnosis and assert the appropriate treatment and the minimization of the probability of malignant transformation of LPD.

Highlights • Be aware of the rare occasion of PE in patients with intestinal obstruction without other etiological factors. • Preoperative diagnosis of PE may be impossible. • Management of PE in case of intestinal obstruction requires urgent surgery., Introduction Peritoneal Encapsulation (PE) is a scarce congenital malformation, characterized by a supplementary peritoneal membrane that covers all or a part of the small intestine. Presentation of case PE was unexpectantly discovered in a young woman during laparotomy for bowel obstruction. There were no specific pre-operative indications of this malformation. The operation was uneventful. Discussion PE is a very rare congenital anatomical anomaly that is difficultly identified pre-operatively. PE is mainly asymptomatic, but in some cases, like in the presented one, PE presents with small bowel obstruction. Surgeons should be aware of this malformation and suspect it when encountering a patient with small bowel obstruction without other etiological factors. Conclusion Knowledge of this peculiar congenital anomaly is pivotal, so that accurate diagnosis and appropriate management of it are direct and efficient.