The aberrant common hepatic artery identified during a Whipple; lessons learned from a difficult case

Abstract

Presenter: Michael Genz MD | Carolinas HealthCare System Background: We report a case of a replaced common hepatic artery originating from the superior mesenteric artery with an anterior course identified during a pylorus preserving pancreaticoduodenectomy. The overall incidence of celiac vascular anatomic aberrancies ranges from 22% - 48%. To our knowledge, there has been only one case report describing this specific anatomic variant that was identified during a planned pancreaticoduodenectomy. Methods: Our patient is a 56-year-old male who presented with obstructive jaundice and found to have a 3cm mass in the head of the pancreas that was found to be adenocarcinoma on fine needle aspiration. He was taken to surgery for a planned open pancreaticoduodenectomy. Intra-operatively, the common hepatic artery was found to be absent from its usual location, along the superior border of the pancreas originating from the celiac trunk. Instead, we identified the common hepatic artery taking off from the superior mesenteric artery, travelling just anterior to the neck of the pancreas and bifurcating into the right and left hepatic arteries at the superior border of the pancreas. This was confirmed on intraoperative ultrasound. The location of the common hepatic artery was found to be sitting anatomically in the area usually occupied by the gastroduodenal artery. We were safely able to dissect the pancreatic head and neck off the common hepatic artery without injury. We then completed the reconstruction, performing a duct-to-duct pancreaticojejunostomy, hepaticojejunostomy and duodenojejunostomy. Results: Cross sectional imaging on post-operative day six demonstrated expected contrast enhancement of the common hepatic, right and left hepatic arteries, confirming no injury had been made during the case. He was eventually discharged on post-operative day elven after resolution of a post-operative ileus. Conclusion: We feel this case stresses the importance of performing a thorough dissection prior to ligating named vessels during a pancreaticoduodenectomy. Failure to correctly identify this type of vascular aberrancy could lead to a disastrous outcome for a patient with this variant.