Unique Hepatic Arterial Pattern Associated With the Presence of Accessory Proper Hepatic Artery and Middle Hepatic Artery.

Vascular variations of the coeliac trunk are relatively common, with documented occurrences including trifurcation of the common hepatic artery (CHA) and the presence of accessory and replaced hepatic arteries. This case report describes a novel variation wherein the CHA trifurcates into the proper hepatic artery (PHA), gastroduodenal artery, and accessory PHA (APHA). This particular trifurcation pattern has not been previously recorded. The APHA further branches into two arteries that supply the right lobe of the liver. Additionally, a middle hepatic artery (MHA), originating from the PHA, was identified alongside the right and left hepatic arteries. The MHA serves as a hilar artery that drains segment IV of the liver. This anatomical variant does not conform to any existing coeliac trunk classifications. Understanding this unique arterial pattern is crucial for liver transplantation, as well as procedures involving the pancreas, duodenum, and gallbladder, and for interventional techniques such as transcatheter arterial chemoembolization and transarterial radionuclide therapy.

Mullan's triangle or anteromedial triangle of the middle cranial fossa: a cadaveric study with its surgical importance.

BACKGROUND: Surgical approaches to the cavernous sinus (CS) and middle cranial fossa (MCF) can be challenging, particularly for young neurosurgeons. The anteromedial (Mullan's) triangle is a triangle by the side of the CS and constitutes part of the floor of the MCF. The contents include the sphenoid sinus, superior ophthalmic vein, and sixth cranial nerve. The literature contains very little research that has precisely defined and measured the anteromedial triangle while considering anatomical variances minimally. METHODOLOGY: The present study was conducted on the skulls of 25 adult human cadavers which were dissected to expose the anteromedial (Mullan's) triangle on both sides. After precisely defining the triangle on each side, measurements of the three borders were taken, and using Heron's formula, the area of each triangle was calculated. RESULTS: On average, the length of the medial border was 12.5 (+ 3.1 mm); the length of the lateral border was 9.9 (+ 3.1 mm); the length of the base was 10.75 (+ 2.4 mm) and the area of the anteromedial triangle was 43.9 (+ 15.06 mm2). CONCLUSION: Precise anatomical knowledge of the Mullan's triangle enables the treatment of disorders in often deformed anatomy or difficult-to-access structures. That is the reason it is important to gain a thorough understanding of the surgical anatomy and to adopt a safe procedure.

Unveiling Morphological Diversity: An Anatomical Investigation of the Foramen Transversarium in the Cervical Vertebrae.

PURPOSE: This study aimed to investigate the morphological variations in the foramen transversarium of the cervical vertebrae and their clinical implications. Understanding these variations is crucial for accurate diagnosis, treatment planning, and surgical procedures involving the cervical spine. MATERIALS AND METHODS: This descriptive cross-sectional study was conducted at the AIl India Institute of Medical Sciences, Bibinagar, India, and involved 150 dry cervical vertebrae specimens. Measurements of the anteroposterior and transverse dimensions, as well as anatomical variations such as accessory foramina and bilateral symmetry, were recorded using vernier calipers. RESULTS: Out of 150 vertebrae, 149 had foramina on both sides, while one had a single foramen on the right. The anteroposterior diameter ranged from 1.0 to 10.0 mm on the right (mean: 5.13 ± 1.25 mm) and 2.0 to 8.5 mm on the left (mean: 5.08 ± 1.11 mm). The transverse diameter ranged from 2.0 to 9.0 mm on the right (mean: 5.54 ± 1.06 mm) and 2.0 to 8.0 mm on the left (mean: 5.42 ± 1.07 mm). Statistical analysis indicated symmetry in morphological dimensions. The morphological variations included unilateral and bilateral accessory foramina, incomplete accessory foramina, and asymmetrical foramina. Circular shapes were predominant (76% on the right, 75% on the left), with other shapes, such as oval and irregular shapes, being less common. CONCLUSION: These findings enhance the understanding of cervical spine anatomy, aiding in the interpretation of radiographic images and the planning of surgical procedures. This research highlights the need for precise anatomical knowledge to improve patient outcomes in cervical spine-related interventions.

Tracking Lymphatic Drainage Pathways Through Inner Ear Channels: A Systematic Review.

The search for potential lymphatic routes through the cochlea, or membranous portions of the inner ear labyrinth, remains a significant challenge. Researchers often focus on lower mammals rather than humans to uncover these pathways. This review aims to delineate the speculated lymphatic routes within the inner ear to date. It follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, conducting a comprehensive search of PubMed, Scopus, Crossref, and Google databases using the terms "inner ear" and "lymph." The problem, intervention, comparison, outcome (PICO) search strategy was employed, and analysis was performed using equation and scope metrics. Articles were screened and filtered using the CADIMA automation tool, resulting in 33 articles being reviewed, of which 23 were selected. Potential lymphatic drainage routes identified include the round window, oval window, scala tympani, spiral limbus, and lateral wall of the cochlea. The vestibular side of Reissner's membrane was noted as a key nodal point for lymphocytes within the inner ear. This review maps the proposed lymphatic networks in the inner ear and highlights existing gaps. It systematically gathers, evaluates, and synthesizes available evidence on the lymphatic pathways of the inner ear, offering valuable insights into their presence, structure, function, and clinical significance.

Transmogrifying Anatomy Learning by Kaizen Strategies and Game-Based Education.

INTRODUCTION: The study explores the significance of continuous improvement through Kaizen in the evolving landscape of anatomy education. In this study, our objectives were twofold: 1) to assess the effectiveness of incorporating games in the first-year medical curriculum for reinforcing anatomy knowledge, and 2) to explore whether game-based sessions elicit improved student responses in the learning of anatomy. METHODOLOGY: A total of 100 first-year Bachelor of Medicine and Bachelor of Surgery (MBBS) students at All India Institute of Medical Sciences (AIIMS), Bibinagar, Hyderabad, Telangana, India, were exposed to game-based learning which involved six rounds: acronym mnemonics (Redolent), jigsaw puzzle solving (Dumbfound), Filling gaps in concept maps (Blogging), Connecting images (Kinship), case scenario creation (Penman), and rapid-fire round (Rattling). RESULTS: At the end of the intervention, a test was taken and feedback was obtained from all the participants using a prevalidated questionnaire prepared based on a 5-point Likert scale. Questionnaire responses were subjected to descriptive analysis, and reliability analysis (Cronbach's α) was performed to evaluate the internal consistencies of items. A paired t-test indicated that there was a significantly large difference between before (mean (M) = 17.2, standard deviation (SD) = 9.1) and after (M = 25.9, SD = 8), t(99) = 18.4, p < .001, signifying that the performance of the students was far better with game-based learning approaches than conventional learning. CONCLUSION: Combining game-based education with Kaizen principles in anatomy education not only prepares students for success in their academic pursuits but also empowers them to navigate the complexities of the ever-evolving healthcare landscape with confidence and proficiency.

Study of confluence of hepatic veins application in liver transplantation.

Liver has exceptional regeneration capacity which makes live donor liver transplantation a good surgical option for patients waiting for donors. Hepatic veins play major role in transplantation surgeries. Variations of hepatic veins can have great impact on surgical approach and outcome of the surgery. In the present study, total number of hepatic veins, presence and absence of accessory veins and confluence with its varied patterns were studied. We found maximum cases with 2 and 3 major hepatic veins which indicate presence of confluence. Confluence between left and middle hepatic veins was highest with 38% of total 54% of cases with confluence. We also found confluence between middle and accessory hepatic vein which is not mentioned in any present classifications. In addition, we have measured confluence length and diameter which holds significance in hepatic resection and anastomosis. The mean confluence length was 0.88±0.39 cm while mean confluence diameter was 0.57±0.20 cm. We found accessory hepatic veins in 15% of cases. The knowledge of this surgical anatomy and associated variations is of paramount importance in liver transplantation, radiological interventional procedures of liver and hepatic tumor resection procedures.

The Dual Innervation of the Gluteus Maximus Associated with Other Anatomical Variations of the Gluteal Region.

The gluteus maximus (GM) is a big quadrilateral musculature that lines the rear portion of the pelvis. It is innervated by the inferior gluteal nerve. The sciatic nerve, inferior gluteal nerve, and posterior cutaneous nerve of the thigh are branches of the sacral plexus. The superior and inferior gluteal arteries are the chief arterial supply to the gluteal region. In the present case, there was a dual innervation of the GM. The superior gluteal artery and the superior gluteal nerve was piercing the piriformis and the inferior gluteal artery was running between the posterior cutaneous nerve of the thigh and the inferior gluteal nerve. According to our literature review, anatomical studies in which this cadaveric procedure has been performed have not been previously reported. The anatomical variations of the gluteal region are important to surgeons, physicians, anatomists, and nurses.

An anomalous pseudoganglion associated with high division of sciatic nerve.

Sciatic nerve (SN) is the thickest and longest nerve of the body. Deviations from the normal anatomical origin and level of bifurcation of SN have been frequently reported. In the present case, we are presenting a unique scenario of origin of terminal branches of the SN-tibial nerve (TN) and common peroneal nerve (CPN) in the pelvic region itself from divisions arising directly from the lumbosacral plexus. This variation was associated with origin of posterior femoral cutaneous nerve from the superior division of CPN with anomalous communicating branches between pudendal nerve and TN. The unique characteristics of the present case are the presence of 'pseudoganglion' found on the inferior division of TN. The present case stands out as the first of its kind to mention such pseudoganglion. Knowledge of some unusual findings like presence of pseudoganglion and intercommunications between nerves have clinical implications in anesthesiology, neurology, sports medicine, and surgery.

Tri-ramification of left external carotid artery associated with anatomical variation of its branches and aneurysm formation.

Essential sources of arterial vascularisation in the head and neck region are the left and right common carotid arteries (CCA) and their branches. The left CCA (LCCA) originates from the arch of the aorta and the right CCA originates from the brachiocephalic trunk. In this case report, there was a bilateral higher division of CCA at the plane of the greater cornua of the hyoid bone, unilateral tri-ramification of the LCCA and the left external carotid artery (LECA), and the origin of the linguo-facial trunk and the pharyngo-occipital trunk from the LECA. An aneurysm formed in the distal part of LECA before its termination. In this case, we propose a novel categorization called the punnapatla classification for the anatomical variance branching forms of ECA. These kinds of variations are important to the surgeons, and anaesthetists, during the surgeries of the head and neck.

Fraser syndrome with limb reduction defect: a rare and unique anatomic variation.

INTRODUCTION: Fraser syndrome, named after George Fraser, is an autosomal recessive disorder showing a highly variable interfamilial phenotypic variation, with malformations ranging from minor symptoms to lethal anomalies like renal agenesis, incompatible with survival. Limb reduction defects have not been reported to be associated with it. CASE PRESENTATION: A 21-year-old primigravida presented to the antenatal outpatient department with a level two targeted anomaly scan report suggestive of severe oligohydramnios with suspected renal agenesis. The cranial vault bones were compressed, and orbital globes and lenses could not be visualized. Renal agenesis was confirmed due to sleeping adrenals sign, non-visualization of the urinary bladder, and Doppler of renal arteries. A detailed examination of the fetal head in the sagittal section showed the absence of an eye globe and lens, arousing suspicion of Fraser syndrome. After pregnancy termination, a complete fetal autopsy was done to look for any additional findings. CONCLUSION: Patients who have a syndromic mix of acrofacial and urogenital abnormalities with or without cryptophthalmos should be evaluated for Fraser syndrome, which can be diagnosed by clinical examination and perinatal autopsy.

Anterolateral surgical triangle of the cavernous sinus: a cadaveric study of neurosurgical importance.

BACKGROUND: The anterolateral triangle around the cavernous sinus is a surgical skull base triangle used as a neurosurgical landmark essential to skull-based surgeries. There are few reports of its measurements with little attention paid to anatomical variations. METHODOLOGY: A total of 15 adult human cadaveric skulls were dissected to expose the anterolateral triangle on both sides. The triangle was defined and measurements of the three borders were taken precisely and the area of each triangle was calculated using Heron's formula. RESULTS: On an average, the length of the anteromedial border is 11.4 (+ 2.2 mm); the length of the posteromedial border is 8.7 (+ 2.6 mm); the length of the lateral border is 13.06 (+ 2.6 mm) and the area of the anterolateral triangle is 48.05 (+ 17.5 mm2). CONCLUSION: Concise understanding of anterolateral triangle is essential to skull-based surgeries; comprehending its anatomy helps with better surgical planning and provides insight into local pathology.

Vulnerabilities of Prostate Glandular Concretions Considered as Artefacts: A Cross-sectional Biopsy Slide Study.

Objective: There is no clear consensus regarding the contour of prostatic glandular intraluminal concretions. This study enlightens the rational approach toward deciphering the true nature of these concretions and evaluates their role in normal routine histology of the prostate gland. Methods: Fifty hematoxylin and eosin slides that were prepared from procured transrectal biopsy specimens of normal prostate glands from asymptomatic patients suspected of having a prostatic disease but later found to be normal were retrospectively observed for the staining, contour, and positioning of the aggregated masses or concretions within their prostatic lumina and were then compared with the blood prostate specific antigen (PSA) levels. Results: Although significant associations highlighting the utility of these masses in presumed pathological states of the gland were drawn by comparing their staining parameters and contours to those of their respective PSA levels, their interluminal contour variations and vivid staining appearances did not necessarily rule out the possibility of some of them being artefacts, provided they were assessed in totality with the surrounding acini. Intensely eosinophilic concretions were found in patients with a high mean age and those with high PSA levels. Conclusions: Prostatic intraluminal masses that were rounded tended to indicate pathological shifts within the gland; however, the possibility of them changing to artefacts during slide preparations could not be ruled out.

Unusual Pattern of Coeliac Trunk and Its Branches: A Cadaveric Study of Two Cases with its Embryological and Clinical Correlation.

The coeliac trunk, the first anterior branch, often originates at the level of the T12 vertebral body, right below the aortic hiatus, as the first ventral branch of the abdominal aorta. It commonly divides into the left gastric, common hepatic, and splenic arteries. We report a rare variation in the branching pattern and course of branches of the coeliac trunk in two donated female cadavers during routine abdominal dissection. It is essential to understand the coeliac trunk and the distinctions in its origin and branching pattern to perform efficient upper abdominal surgical and radiological procedures and to adopt novel interventional and treatment options for hepatic cancers. As anatomists, we are also attempting to link our study's variations to their embryological genesis.

Azygos anterior cerebral artery associated with hypoplastic A1 fragment of right anterior cerebral artery.

Anterior cerebral arteries are paired and supply the major portion of the medial surface of the brain. They are branches of the intracranial part of the internal carotid artery and form the anterior portion of the circle of Willis (CW) which is situated in the interpeduncular fossa. During routine dissection in the department of anatomy, All India Institute of Medical Sciences, Bibinagar, Hyderabad, a rare variation had been observed in the CW, azygos anterior cerebral artery associated with hypoplastic A1 fragment of the right anterior cerebral artery in a 63-year-old female cadaver. It is important to identify and study this kind of rare variation for surgeons, anatomists, and radiologists during dissection, surgical, radiological, and diagnostic interventions.

A study on the congruence and proximity of the sling and clasp fibres at the cardio-esophageal junction of the stomach.

BACKGROUND AND AIM: The cardio-oesophageal sphincter that is located in close longitudinal proximity to the origin of the lesser curvature of the stomach has a unique pattern of external muscle fibres whose inner oblique layer would normally form an elongated sling and the middle partially circular layer would form a projecting clasp into the already existing muscular sling of the former congruently, which would result in the formation of an anatomical sphincter in that area that would normally be devoid of the external longitudinal muscle layer coat. Certain authors have disagreed with the notion of this standard literature and have proposed that the clasp and sling fibres need not necessarily be congruent and may even remain independent of each other with partial contributions from the longitudinal muscle layers as well that may arise tangentially in different populations, which may in turn contribute to reflux oesophagitis in that population. Hence, the clasp and sling fibre muscular patterns were observed in six formalin-embalmed cadavers at the department of anatomy in a tertiary care institute as part of routine dissections in series, and the findings were then reported. FINDINGS: At the junction of the lesser curvature of the stomach with the oesophagus, all six cadavers showed a longitudinal sling pattern as opposed to the conventional oblique sling. The circular muscle layer was found to be merged with the outer longitudinal muscle layer to form the sling that pulled away from the clasp, resulting in a loss of congruency for the same. The clasp fibres, however, were found to be contributed by the inner oblique muscle layer. The conventional perpendicular or tangential merging of the clasp with the sling was not observed; instead, an obtuse, blunt angular merging of the clasp with the sling was observed. DISCUSSION: The deviation of the sling from the clasp could indicate a lack of a proper fit between them at the cardio-oesophageal sphincter. The lack of robustness in the attachment of the clasp to the sling may possibly contribute to the diminished taut pull of the clasp in this subset of the population. These would be significant determinants for a predisposition to reflux oesophagitis and Barrett's oesophagus.

Anatomical variation of quadratus plantae in relation with flexor digitorum brevis.

The muscles of the sole have been traditionally categorized into four layers, but it is more practical to divide them into peripheral and central groups. The peripheral groups include medial and lateral groups. The central plantar muscles are more numerous and divided into superficial and deep layers. During routine dissection in the Department of Anatomy, All India Institute of Medical Sciences Bibinagar, Hyderabad, variations are been observed in the plantar intrinsic muscle in the left foot & right foot of a 53-year-old male cadaver. This is the first cadaveric report of a combination of discrepancies especially the inter-tendinous connection between quadratus plantae and flexor digitorum brevis. Similar observations in the literature were not found by us. It is important to identify and study these dissimilarities of muscles of the sole for surgeons, anatomists, radiologists and orthopaedics as these muscles and tendons are used in foot reconstructive procedures, and for the treatment of some congenital anomalies.

Innovative Cadaver Preservation Techniques: a Systematic Review.

Cadaveric dissection is a unique and unrivalled educational tool that allows students in medicine and associated life sciences to explore spatial three-dimensional anatomy, principles of structure and related function, and anatomical variations, including pathological alterations. Human tissue dissection enables researchers to comprehend the variety that exists in life that cannot be appreciated through the literature or artificial specimens. Using cadavers is the best way to simulate surgical and anatomical teaching. A cadaver has been shown to imitate surgical and anatomical training better than any other existing method. By the use of soft embalming approaches, cadavers have become more realistic and training-friendly. The main aim of this review is to describe various innovative and recent cadaver preservation techniques in detail, which can help anatomists to modify the techniques in their institute for gross anatomy teaching and surgical training or workshops to get a lifelike cadaver.

A Rare Variation of Plantar Interossei Muscles of the Foot - a Case Report.

The variations in the attachment of plantar interossei might affect the gait of the individual and also raise questions about the function of this muscle at the tarsometatarsal joints. During routine dissection of the right lower limb, we encountered a unique variation in the attachment of plantar interossei. The first plantar interossei took origin from the lateral side of the base of the first metatarsal and inserted into the lateral side of the base of the proximal phalanx of the great toe. The second and third plantar interossei took origin from the medial surface of the base of the second and third metatarsals, respectively, and inserted into the medial side of the base of the proximal phalanges of the corresponding digits. The third and fourth intermetatarsal spaces were void, indicating the absence of these muscles from those spaces. The clinical significance of this variation has been discussed.

Importance of online self-assisted assessments for medical students in knowledge acquisition.

BACKGROUND: Assessment is an important aspect of teaching and learning in medical education. Regular early assessments create scope for improvement in students, and this digital era technology should be utilized for ease of administration. E-assessment involves the usage of technology to create, deliver, collect, and provide feedback to the students. The present study aims to understand the importance of online assessment and the preference of students with difficulties faced and the methods of improvement. METHODS AND MATERIALS: This study was a cross-sectional descriptive study conducted among fifty-six undergraduate medical students, where forty-five objective structured practical questions (OSPEs) were administered to the students in anatomy. After the assessment, feedback was collected in the form of a fifteen-item questionnaire. The responses were graded using a five-point Likert scale and represented in the graphs using Microsoft Excel software. RESULTS: The feedback collected has the following responses. The prosected specimen pictures used in the exam, with pointers and markers, were clear and oriented for which 77% agreed, the pointers and markers were clear and easy to identify for which 79% agreed, and 66% preferred the traditional method of assessment over the online mode of assessment and 48% were neutral on the question of whether E-assessment improves knowledge and skills. Most of the students preferred the traditional method of assessment over the online method of assessment. CONCLUSIONS: Traditional methods of teaching or assessment cannot be replaced by online methods, but technology can be utilized as an addition to regular mode to improve the outcome. Regular early formative assessments help teachers to understand areas of deficiency and help students in improvement. E-assessment can be adapted for formative assessment and regular practice because of their ease of administering and providing feedback simultaneously.

A Rare Variation of High Division of the Sciatic Nerve and Associated Neuromuscular Variations in the Gluteal Region.

Variations in the anatomical division of the sciatic nerve are not uncommon. In this case report, we are presenting a rare variation of the sciatic nerve in relation to the superior gemellus and the presence of anomalous muscle. To the best of our knowledge, the anomalous communicating branches of the posterior cutaneous femoral nerve with tibial and common peroneal nerve and the presence of an anomalous muscle originating from the greater sciatic notch and inserting at ischial tuberosity have not been reported yet in the literature. This anomalous muscle found can be named as 'Sciaticotuberosus' after its origin and insertion. Such variations hold clinical significance as they may contribute to piriformis syndrome, coccydynia, non-discogenic sciatica, and popliteal fossa block failure leading to local anesthesia toxicity and blood vessel traumatization. The current classifications of division of the sciatic nerve are based on its relation to the piriformis muscle. In our case report, the variation of the sciatic nerve in relation to the superior gemellus suggests the need for the revision of current classification systems. Category-like division of the sciatic nerve in relation to the superior gemellus muscle can be added.