Aberrant Vasculature During Minimally Invasive Transhiatal Esophagogastrectomy

Abstract

Fig 3. Aadenocarcinoma of the gastroesophageal junction. He underwent neoadjuvant chemotherapy and radiation therapy followed by a minimally invasive transhiatal esophagogastrectomy. Duringmobilization of the stomach, a suspected aberrant left hepatic artery (LHA) was identified within the gastrohepatic ligament (Fig 1). Given the extent of residual celiac nodal disease, a complete celiac dissection and lymphadenectomy was performed, including skeletonization of the left gastric artery (LGA) and aberrant LHA (Fig 2; IVC, inferior vena cava). Careful attention was then paid to ligating the LGA distal to the aberrant LHA takeoff to preserve hepatic arterial supply. Three-dimensional reconstructions of the preoperative imaging were able to elucidate the aberrant anatomy, revealing a replaced LHA. Further, the patient also had a replaced right hepatic artery (RHA) branching from the superior mesenteric artery (Fig 3). A critical pitfall of an esophagogastrectomy is recognizing and preserving aberrant hepatic vasculature to prevent subsequent hepatic ischemia. A replaced LHA originating from the LGA is an anomaly found in up to 10% of people [1]. It is important to work with radiology colleagues to perform time contrast studies to allow for clear delineation of aberrant anatomy, as well as to view in detail axial and coronal projections. Finally, awareness