Search

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.

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.

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.

Highlights • Massive localized lymphedema (MLL) constitutes a rare benign clinical disorder, presenting in obese patients, characterized by chronic accumulation of lymph and adipose tissue due to lymphatic flow obstruction. • MLL may mimic an abundance of soft tissue tumors. • Nevertheless, surgical excision of the soft-tissue mass, seems the most favorable therapeutic approach, as performed in the presented case., 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.

Right or subtotal colectomy either open or laparoscopic may be a challenging operation owing to technical difficulties. One of these, is to identify a safe and adequate dissection plane, ligating and dissecting lymph nodes around middle colic vessels. The purpose of this study was to depict a rare anatomic variation of middle colic vein (MCV) draining to splenic vein. We report the case of a 55-year-old male patient, who was subjected to a right hemicolectomy for an adenocarcinoma in the ascending colon. During dissecting the transverse mesocolon from the greater omentum, for complete mesocolic excision (CME), we encountered that the MCV drained in the splenic vein. With respect of this rare anatomic variability, CME was completed without hemorrhage. Our aim is to depict that deep knowledge of MCV anatomy and its variations is of paramount importance to achieve CME and to avoid dangerous or massive bleeding.

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.

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.

Acute appendicitis within a femoral hernia is a rare condition that was first described by Rene Jacques de Garengeot. In the present study, we summarize the existing evidence on de Garengeot's hernia, with special emphasis on its clinical presentation and diagnostic approach.A thorough search of the English-language literature published between 1980 and 2011 was performed. Studies reporting cases of de Garengeot's hernia were selected using specific inclusion criteria (description of femoral hernia appendicitis, statement of patient demographics and symptoms, and statement of diagnostic tests performed).Thirty-one studies that encompassed 36 patients (28 women, mean age 71.5 years) with de Garengeot's hernia were included in our analysis. Patients presented with a right groin mass in 35 (97 %) cases. The mass was almost always painful (n = 35, 97 %), while 14 (39 %) of the patients were febrile. Mean duration of symptoms was 5.17 days. Fifty-six percent of the groin masses were erythematous. Leukocytosis was present in 67 % of the patients, and 25 patients underwent imaging investigation with X-ray (n = 11), Ultrasound (n = 5) or Computed Tomography (CT, n = 9). Twenty percent of the Ultrasound and 44 % of the CT studies were diagnostic, leading to an overall rate of 14 % of femoral hernia appendicitis preoperative diagnosis. Eighty-one percent of the patients underwent herniorrhaphy with sutures while a mesh was used in 19 %. Mean hospital stay was 6.23 days.Preoperative diagnosis of de Garengeot's hernia is difficult due to its atypical clinical presentation. Further surgical treatment depends on the surgeon's sound clinical judgment.

MYCN is a well-known oncogene overexpressed in different human malignancies including neuroblastoma, rhabdomyosarcoma, medulloblastoma, astrocytoma, Wilms’ tumor, and small cell lung cancer. While neuroblastoma is one of the most common childhood malignancies, in adults it is extremely rare and its treatment is based on pediatric protocols that take into consideration stage and genotypic features, such as MYCN amplification. Although neuroblastoma therapy has evolved, identification of early stage patients who need chemotherapy continues to pose a therapeutic challenge. The emerging prognostic role of MYCN phenotype of this disease is currently under investigation as it may redefine MYCN amplified subgroups. We describe an unusual case of adult neuroblastoma with MYCN amplification diagnosed incidentally and discuss possible therapeutic dilemmas.

Splenosis is a common benign condition that occurs after splenic rupture via trauma or surgery. The mechanism behind splenic cell autotransplantation begins with the splenic rupture, either from trauma or surgical removal. Splenosis is usually found incidentally and, unless symptomatic, surgical therapy is not indicated. Subcutaneous splenosis is an extremely rare form of splenosis, mostly observed in abdominal surgical scars. We report a case of subcutaneous splenosis, as well as a comprehensive review of the literature. In our case, a 43-year-old woman who had splenectomy after traumatic splenic rupture at the age of 7 years old presented for plastic reconstruction of her postoperative scar. Upon surgery, two asymptomatic subcutaneous nodules were incidentally discovered. The presence of splenic tissue was confirmed by the histological study. The nodules were not excised, as the patient was not symptomatic.

IntroductionThe presence of the appendix in a femoral hernia sac is known as de Garengeot's hernia. We report a rare case of an elderly woman with femoral hernia appendicitis and discuss the surgical pitfalls and considerations through a literature review.Presentation of caseAn 83-year-old woman presented with fever and right lower quadrant abdominal pain. Clinical examination revealed a femoral hernia. Ultrasonography confirmed bowel was present in the hernia sac. In the operation room, an acutely inflamed appendix was recognized within the sac. The patient underwent appendectomy and hernia repair with sutures.DiscussionAcute appendicitis within a femoral hernia is rare and multiple dilemmas exist regarding its treatment. An incision below the inguinal ligament is a reasonable choice in order to access the hernia sac. A mesh should be placed in non-infectious appendectomy while herniorrhaphy is preferred in cases of appendicitis.ConclusionThe presence of the vermiform appendix in a femoral hernia sac is rare but the surgeon should be aware of this clinical entity. Prompt diagnosis and appropriate surgical treatment is the key to avoid complications.

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.