Accessory Left Hepatic Artery Research Articles

C4 (Clinical Case) Vascular Ehlers-Danlos Syndrome in the Paediatric Population: A Case Report of an Internal Bleed Caused by Ruptured Pseudoaneurysm

Abstract Introduction/Background Ehlers-Danols syndrome (EDS) is a connective tissue disease characterized by joint hypermobility, skin hyperextensibility and tissue fragility. EDS has six types. Type IV EDS: vascular EDS (vEDS), is rare but also the most malignant. Case Description We report a 15-year-old boy with a previous history of spontaneous colon perforation and two left shoulder dislocations. He presented with sudden onset abdominal pain, vomiting, dizziness, and lethargy with a Glasgow coma scale of 13. His abdomen was soft but mildly tender. He had a capillary refill of 3 seconds with cold extremities, was found to be in a hypotensive shock state requiring resuscitation with fluids and inotropes, as well as intubation and mechanical ventilation. His hemoglobin dropped by 30 g/L in 6 hours. Therefore, an abdominal ultrasound was done, revealing an intrabdominal hematoma. CT scan of the abdomen confirmed a ruptured fusiform pseudoaneurysm of the accessory left hepatic artery. This was successfully managed by coil embolization, see F1 and F2, below. Genetic workup was positive for the pathogenic COL3A1 gene that presents phenotypically as Ehlers-Danlos syndrome, particularly type IV. Discussion COL3A1 encodes pro-alpha1 chains of type III collagen. Inheritance is autosomal-dominant. It can present as a de novo variant with a negative family history, as was the situation for our patient. Estimated affected people with de novo variant vEDS is 33%-50%. Clinical diagnosis of vEDS involves one major and several minor criteria (2017). Major criteria include arterial aneurysms, dissection, or rupture; intestinal rupture; uterine rupture during pregnancy; family history of vEDS. Minor criteria include easy bruising; thin skin and visible veins; facial characteristics including prominent eyes, narrow nasal bridge, thin lips; club foot, congenital hip dislocation; inguinal hernia and pneumothorax. Our patient had two elements from the major criteria: arterial pseudoaneurysm and intestinal rupture. Conclusion vEDS has high morbidity and mortality due to the risk of spontaneous internal organ/vessel injury. This can be mitigated by increased awareness of systemic manifestations of vEDS and a high index of suspicion by both primary care and emergency physicians. Once diagnosed, surveillance is crucial, including regular blood pressure monitoring, frequent non-invasive imaging to identify emerging vascular lesions, and pregnancy counselling for potential uterine rupture and avoiding trauma, collision sports, and lifting heavy items.

Effect of accessory hepatic artery reconstruction on prognosis in orthotopic liver transplantation: a single center experience

BackgroundIn orthotopic liver transplantation (OLT), preserving an aberrant hepatic artery (AHA) can increase the number of arterial anastomoses and may lead to arterial-related complications. AHA includes accessory hepatic artery and replaced hepatic artery. Herein, the purpose of our research is to evaluate the requirement for accessory anastomosis in OLT.MethodsWe retrospectively reviewed a total of 95 patients who underwent OLT in our hospital between April 2020 and December 2022. We found seven cases of donor livers with accessory HA. The method of arterial anastomosis and details of the diagnosis and treatment of complications were collated.ResultsAmong 95 consecutive patients with OLT, complications occurred in two of seven patients—patient 2 had an accessory right hepatic artery, while patient 5 had an accessory left hepatic artery. Patient 2 showed bile leakage leading to rupture and bleeding of the accessory HA anastomosis after OLT, and was treated with interventional coil embolization. In patient 5, hepatic artery thrombosis and accessory HA occlusion were treated with embolization and thrombolysis of the splenic artery and left gastric artery. During the intervention, we also found that the internal hepatic artery and accessory HA had communicating branches. After treatment, both patients remain healthy with no complications such as liver necrosis or liver abscess.ConclusionAn AHA can be ligated when assessed as an accessory artery. This can reduce the incidence of arterial complications, contribute to the perioperative management of liver transplantation (LT) patients, and improve the prognosis of LT.

Laparoscopic Hepatectomy for Giant Hepatic Hemangioma Using the Involved Intrahepatic Anatomic Markers Approach

BackgroundHepatic hemangioma has been one of the absolute indications of laparoscopic hepatectomy (LH).1 However, the risk of catastrophic intraoperative bleeding and the difficulty to control it make the laparoscopic treatment of giant hepatic hemangioma (GHH) a technical challenge for hepatobiliary surgeons.2 Herein, we presented a video of LH for GHH using the involved intrahepatic anatomic markers approach. MethodsA 22-year-old female was referred for treatment of an intractable GHH (18 cm), which involved the left hepatic pedicle, left hepatic vein (LHV), and middle hepatic vein (MHV), resulting in the invisibility of the above intrahepatic anatomic markers on CT. The procedure was performed according to the following steps: (1) dissecting and ligating the left hepatic artery (LHA) and left portal vein (LPV) via intrafascial approach, respectively; (2) cutting the accessory LHA; (3) transecting parenchymal along the demarcation line in a caudal-to-cranial direction and exposing the involved caudal middle hepatic vein (MHV); (4) isolating and transecting the involved left hepatic duct; (5) preserving the integrity of involved MHV; (6) isolating and transecting the left hepatic vein (LHV) and splenic vein (SV); (7) mincing and extracting the specimen. This study was approved by the West China Hospital Ethics Committee and was conducted in accordance with the ethical guidelines of the Declaration of Helsinki. All treatments were performed after obtaining written informed consent from the patients. ResultsThe operative time was 286 min, and blood loss during operation was 160 ml. This procedure ensured the integrity of MHV and maximized the residual functional hepatic volume. The histopathologic examination confirmed the hepatic cavernous hemangioma. The patient had an uneventful postoperative recovery and was discharged on the fifth day after operation. ConclusionLH using the involved intrahepatic anatomic markers approach is feasible and effective for intractable GHH. Its advantages lie in decreasing the risk of disastrous hemorrhage or open conversion rate while maximizing the postoperative functional hepatic reserve.3

Prevalence of hepatic vascular anomalies in consecutive contrast-enhanced computed tomography images — a retrospective observational study

BackgroundLiver is a complex, highly vascular organ, where anatomical variations are the norm. This study aimed to analyze all the three hepatic vascular anatomical variations in a single study which would help us understand the prevalence of hepatic vascular (arterial, portal, venous) anomalies in the population catered to by our institution.MethodsA retrospective analysis of 545 contrast-enhanced CT scans was done from November 2019 from the institute PACS after satisfying the inclusion and exclusion criteria. The raw imaging data were processed in PACS software — Centricity™ Universal Viewer and Syngo.via Vb20 platform, for axial, coronal, and axial-oblique multiplanar reformation, maximum intensity projection (MIP), and volume rendering (VR) images. Data were analyzed in the three vascular phases to determine the anatomical variations. Analysis was done by two surgical residents in the division of HPB surgery, which was verified by a certified radiologist.ResultsThere were no major differences in the prevalence rates of the vascular anomalies across gender and domicile distributions. The prevalence of normal hepatic artery and variant hepatic artery in our study was 69% and 31%, respectively. Accessory left hepatic artery (10%) was the most common hepatic artery variant in our study. Single RHV was seen in 77.4%, and other RHV variants like two RHV with common trunk, two RHV with independent drainage, and three RHV with common trunk contribute 22.6% of our study population. Accessory inferior RHV was seen in 19.8% of the study population. Normal portal vein anatomy was found in 81.1% in our study, and the most common variant in our study population was trifurcation of portal vein (16.1%).ConclusionThis was the largest study until date from South India, studying all three hepatic vascular anatomical variations in a single study. Variations in the anatomy of hepatic arteries, portal veins, and hepatic veins are common. A good knowledge of the same is necessary especially for a hepatobiliary surgeon or for an interventional radiologist, to plan and avoid complications during a procedure. Preoperative contrast-enhanced CT scan and whenever necessary a VR or a MIP reconstruction will precisely help in identifying these variations.

Anatomical variations of the hepatic artery in it's extra hepatic journey: a cadaveric study with its clinical implications.

Vascular anomalies are a serendipitous finding during surgeries and diagnostic angiography. Such variations are frequently encountered in the abdominal region. These anomalies are usually asymptomatic but the presence of hepatic arterial variations may lead to injuries of the liver during surgery. The present study was conducted on 35 adult embalmed cadavers, 31 males, 4 females from August 2015 to December 2021 in the Department of Anatomy, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi. In this study of 35 cadavers, we present 3 variants: an accessory right hepatic artery, replaced common hepatic artery, replaced common hepatic artery anastomosis with accessory left hepatic artery and an arc of Buhler. One of our variants has not yielded a precedent in literature search. We have compared these variants with Michels and Hiatt classification. It is known that different variants arise at distinct stages of embryonic development. As specialists in anatomy, we have tried to correlate the variants in our study with their embryological origins.

CT Angiographic Study on the Variations of the Hepatic Arteries in the Living Liver Donors of the South Indian Population.

Living liver donor transplantation is the last option for the end stage liver diseases. The variations in the hepatic artery of the liver donor may lead to poor outcome, or may end with major post-operative complications such as hepatic artery thrombosis. To prevent the post-operative complications and to increase the success rate of the liver transplant surgeries, CT evaluation of the hepatic arteries is essential. Thus, the present study was aimed to study the variations of the hepatic arteries in the living liver donors. A total of 200 CT angiograms were collected from the department of Radiology from August 2018 to December 2021, and the evaluation was carried out in the Department of Anatomy, Deccan College of Medical Sciences, Hyderabad. All the CT angiograms were studied for the variations of hepatic arterial system, and the observed variations were noted and the incidence was calculated. The normal anatomy was observed in 62.5% liver donors and 37.55% of liver donors showed variations in hepatic arterial pattern. The incidence of the replaced left hepatic retry, replaced right artery, replaced left along with replaced right hepatic artery was observed as 11.5%, 9.5% and 3% respectively. The incidence of left and right accessory hepatic arteries was 7% and 4% respectively and the replaced right hepatic artery with accessory left hepatic artery was observed in 1.5% cases. The variations observed in the hepatic arterial pattern observed in this study could be helpful to the surgeons, while planning and selecting the suitable liver donors and also may minimise the risk and increase the success rate.Â

Ex situ arterial reconstruction prior normothermic machine perfusion of liver grafts

PurposeAtypical variants of the hepatic artery are common and pose a technical challenge for normothermic machine perfusion (NMP). The transplant surgeon has three options when confronted with hepatic arterial variation in a liver graft to be subjected to NMP: to perform arterial reconstruction (i) prior, (ii) during, or (iii) following NMP.MethodsHerein, we report our experience and technical considerations with pre-NMP reconstruction. Out of 52 livers, 9 had an atypical hepatic artery (HA): 3 replaced right HA, 3 replaced left HA, 1 accessory left HA, 1 accessory left and right HA, and 1 replaced left and right HA.ResultsReconstruction was conducted during back-table preparation. A single vascular conduit was created in all grafts to allow single arterial cannulation for NMP, necessitating only one arterial anastomosis within the recipient. All grafts were subjected to NMP and subsequently successfully transplanted.ConclusionOur approach is being advocated for as it preserves the ability to alter the reconstruction in case of problems resulting from the reconstruction itself, thereby allowing functional evaluation of the reconstruction prior transplantation, permitting simultaneous reperfusion in the recipient, and providing the shortest possible duration for vascular reconstruction once the graft is rewarming non-perfused within the recipient. In addition, in light of the frequency of technically demanding reconstructions with very small vessels, we consider our technique beneficial as the procedure can be performed under ideal conditions at the back-table.

Percutaneous Trans-Hepatic Embolization of an Iatrogenic Extra-Hepatic Pseudoaneurysm of the Right Hepatic Artery in a Patient With Previous Occlusion of the Proper Hepatic Artery: An Endovascular Procedure to Avoid a Difficult Surgical Repair

We report a case of successful percutaneous transhepatic, embolization of an iatrogenic extra-hepatic pseudoaneurysm (PsA) of the right hepatic artery (RHA) under combined fluoroscopic and ultrasonographic guidance. A 73-year-old man underwent percutaneous transhepatic biliary drainage placement in another hospital, complicated by haemobilia and development of a RHA PsA. Endovascular embolization was attempted, resulting in coil embolization of the proper hepatic artery, and persistence of the PsA. At this point, the patient was referred to our hospital. Computed tomography and direct angiography confirmed the iatrogenic extra-hepatic PsA of the RHA, refilled by small collaterals from the accessory left hepatic artery (LHA) and coil occlusion of the proper hepatic artery. Attempted selective catheterization of these vessels was unsuccessful due to the tortuosity and very small caliber of the intra-hepatic collaterals, the latter precluding endovascular treatment of the PsA. Percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA was performed with Lipiodol® and cyanoacrylate-based glue (Glubran®2). Real time fluoroscopic images and computed tomography confirmed complete occlusion of the pseudoaneurysm. Surgical repair, although feasible, was considered at high risk. In our patient, we decided to perform a percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA using a mix of Lipiodol® and Glubran®2 because of the fast polymerization time of the glue allowing the complete occlusion of the PsA in few seconds, thus eliminating the risk of coil migration, reducing the risk of PsA rupture and avoid a difficult surgical repair.

Branching Pattern Variations of the Celiac Trunk and Superior Mesenteric Arteries in a 94‐Year‐Old White Female Cadaver

Recognizing the presence of abdominal vascular anatomical variations in patients is imperative for surgeons who perform major abdominal surgeries, vascular interventionalists performing ablations or embolizations, and oncologists administering targeted chemotherapies. Neglecting to identify such variations can lead to significant patient morbidity and mortality. It is similarly important to anatomical instructors in the education of future medical providers. During cadaveric dissection of fifty-six cadavers, we observed several unique anatomical variations occurring within the major enteric vessels of the abdomen of a 94-year-old white female cadaver. These variations included a celiac trunk that gave rise to bilateral inferior phrenic arteries, the splenic artery, and a gastrohepatic artery that gave off the left gastric artery, an accessory left hepatic artery, and then continued as a common hepatic artery. Shortly from its origin, the common hepatic artery then trifurcated into a large gastroduodenal artery, the right hepatic artery, and the left hepatic artery. There was no definitive proper hepatic artery present. The accessory left hepatic artery gave off an accessory left gastric artery. The cystic artery derived directly from the superior mesenteric artery, and the middle colic artery arose from the gastroduodenal artery. The middle colic artery also had an accessory aberrant left colic artery branching from it. These anatomical variations described herein are of both clinical significance and academic consequence. While single anatomic variations are well described, the presence of multiple, complex variations in a single patient, such as those described here, is less common in the literature. To our knowledge, there are no other reports of this combination of variations in the literature to date. Operating surgeons and vascular interventionalists should be aware of these variants as they occur both individually and in combination while treating diverse patient populations. Accordingly, the developmental and clinical significance of these anomalous vessels is discussed here.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report

PurposeAnnular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety.MethodsCase report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum.ResultsContrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival.ConclusionThis was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

Laparoscopic caudate lobe re-resection in an obese patient with cirrhosis: a himalayan approach

We present the video of a laparoscopic caudate lobe repeat resection for a bifocal hepatocellular carcinoma (HCC) recurrence in a 67-year-old male with a history of HBV-, HCV- and metabolic-related cirrhosis, obesity, type-II diabetes, hypertension. The patient had previously undergone a partial laparoscopic resection of the caudate process with cholecystectomy in 2016 for a 55 mm G2 HCC. After four years, follow up CT and MRI showed a bifocal HCC recurrence of 22 and 10 mm in the paracaval portion of the remaining caudate process. After extensive adhesiolysis and caval exposure, the lesser omentum and accessory left hepatic artery were sectioned to expose the caudate lobe, which was then detached from the plane of the inferior vena cava by sectioning the Spigelian veins. During this maneuver, a clip on a 4mm Spigelian vein fell, causing a bleeding that was controlled with forceps and repaired with a 3/0 Polyglactin running suture. Half-way through the parenchymal transection, the pneumoperitoneum was interrupted due to insufflation problems. At reinsufflation, the patient went into cardiac arrest. CPR was performed, with return of spontaneous circulation after one minute. Cardiolpulmonary events were excluded but, due to worsening acidosis, the operation was interrupted and the patient was taken to the ICU for monitoring and stabilization. The next day, after a night of bivouac and lactate clearance, the operation was concluded as a hand-assisted procedure. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Histological examination showed a bifocal pT2 G1 HCC.

Evaluation of Celiac Trunk, Hepatic Artery Variations, and Their Collateral Arteries by Multi-Slice Computed Tomography.

Objectives:Celiac Trunk (CT) is a vital artery and the first unmatched branch of the abdominal aorta, providing blood to upper abdominal structures, particularly the liver, stomach, and spleen. It is essential to know its anatomy in terms of pancreas, spleen, gallbladder, liver surgeries, and interventional radiological procedures such as chemoembolization. The aim of our study is to contribute to the literature with the measurements of distances between the diaphragmatic crus and vascular structures with their diameters, which have been studied insufficiently, and to detect the possible relationships between vascular variations and collateral branches.Methods:Imaging findings of 200 patients (114 males and 86 females), who underwent Multi-Section Computed Tomography examination with various indications in our center between June 2016 and July 2020, were retrospectively analyzed. The statistical relations between CT and Hepatic Artery variations, collateral formations, age, and gender were evaluated with the Spearman’s Rho Correlation Coefficient Test.Results:The distance between the crus of diaphragm and CT was 4–60 mm (mean 24.3 mm), the distance between CT and superior mesenteric artery (SMA) was 2.5–35 mm (mean 8.6 mm), CT diameter was 4.6–9.4 mm (mean 7.3 mm), and the main hepatic artery diameter was 2.4–5.8 mm (mean 4.1 mm). There was no correlation in our study between CT, Hepatic Artery variations, and their collaterals (r in range of −20,124–0.116, p>0.05). It can be said that in cases of the single accessory left hepatic artery originating from the left gastric artery, such as Michel’s Type V and Type VIII, collaterals between common hepatic artery and SMA were relatively more frequent (p=0.1).Conclusion:Our study contributed to the literature by measuring the distance between diaphragmatic crus-vascular structures, which has been little studied in the past. Frequencies of CT and Hepatic Artery variations that have been detected in our study are similar to the results of the previous studies with non-malignancy patient groups.

A single-center clinical study of hepatic artery variations in laparoscopic pancreaticoduodenectomy: A retrospective analysis of data from 218 cases.

Hepatic artery variations increase the difficulty of laparoscopic pancreaticoduodenectomy (LPD). The safety and efficacy of LPD in the presence of aberrant hepatic arteries (AHA) must be further verified.Patients with normal and variant hepatic arteries who underwent LPD and preoperative arterial angiography were retrospectively analyzed. Variation type, intraoperative management, and clinical treatment outcomes were compared.There were 54 cases (24.8%) of AHA. The most common hepatic artery variation was accessory right hepatic artery (RHA) from the superior mesenteric artery (SMA, n = 12, 5.5%), followed by replaced RHA from the SMA (n = 10, 4.6%), accessory left hepatic artery from the SMA (n = 10, 4.6%), and replaced common hepatic artery from the SMA (n = 6, 2.8%). Each type of arterial variation was successfully preserved in all cases, and there were no significant effects on the evaluated surgical indices, conversion rate, incidence of postoperative complications, or follow-up results.Our findings indicated that preservation of AHAs during total LPD is feasible. There were no significant effects on surgical indices, incidence of postoperative complications, or follow-up outcomes.The influence of AHA on the safety and efficacy of LPD must be further verified. Patients with normal and variant hepatic arteries who underwent LPD and preoperative arterial angiography were retrospectively analyzed. There were 54 cases (24.8%) of AHA. There were no significant effects of AHAs on surgical indices, incidence of postoperative complications, or follow-up outcomes.

Safety of Ligation of Aberrant Left Hepatic Artery Originating from Left Gastric Artery in Laparoscopic Gastrectomy for Gastric Cancer

There are still lot of controversies whether aberrant left hepatic artery (ALHA) originating from left gastric artery should be ligated or preserved during gastric cancer (GC) surgery. We aimed to investigate this issue. We reviewed ALHA cases who had laparoscopic gastrectomy for gastric cancer at Seoul National University Hospital (SNUH) from 2012 to 2016. Type of ALHA variants using Michel’s classification of hepatic arterial anatomy and diameter of each vessel were evaluated by 2 radiologists. Postoperative hepatic function and surgical outcome were collected until 6 months after surgery. Results showed that if the diameter of ALHA was larger than 1.5 mm, a transient elevation of SGOT and SGPT on postoperative day 2 was observed in the ligated cases. No differences were observed in operation time, amount of blood loss, overall complication rate, hospital stay, and number of lymph nodes retrieved between the ligated and preserved replaced left hepatic artery (RLHA) and accessory left hepatic artery (acLHA) group. In this study, we conclude that ligation of ALHA seems to be safe as none of the patients suffered adverse outcome. A transient rise in postoperative SGOT and SGPT levels were seen after ligating ALHA >1.5 mm in diameter regardless of subtype.

Role of CT Angiography in the Evaluation of Tumour Vascular Relationship in Patients with Pancreatic Tumours

Abstract Background: Pancreatic cancer is the fourth leading cause of cancer related deaths worldwide. It has poor prognosis especially in locally advanced tumours. Treatment of pancreatic tumours remains a challenge regarding their growth into the adjacent anatomical and vascular structures. Multidetector computed tomography (MDCT) plays an important role in diagnosing of patients with resectable and borderline resectable tumours. Evaluation of borderline resectable tumours should involve the accurate identification of the relationship between the tumour and the surrounding vessels and other vital struc-tures. Aim of Study: Evaluation of the role of CT angiography in the assessment of tumor vascular relationship in patients with pancreatic tumors in order to choose the proper treatment decision. Material and Methods: This study is a prospective study which was conducted in the Radiology Department of Man-soura University Hospital over the period from August 2016 to September 2019. This study included 79 patients, their ages ranged from 45 to 74 years old with mean age 58.3 years old. All patients were referred from oncology Center of Mansoura University and outpatient surgery clinics. The study was approved by our institution's ethics committee, and all patients gave their informed consent before inclusion in the study. CT scans were obtained with a MDCT scanner (Aquilion 64, Toshiba Medical Systems). CT protocols for pancreatic imaging vary at different institutions but typically include a multiphasic technique with a very thin section imaging and multiplanar reconstruction. Contrast enhanced images include: A late arterial or pancreatic phase and a portal or venous phase after injection of 100-120mL of intravenous non-ionic water soluble contrast material usually at rate of 4-5mL/sec. Results: This study included 79 patients, their ages ranged from 45 to 74 years old with mean age was 58.3 years. The most common affected site in the pancreas was the pancreatic head (47 lesions). All the lesions in our study were histopatho-logical proven malignant. The most common histopathological type in our study was pancreatic adenocarcinoma representing 61 lesions (77.21%). As regards the CT appearance of the pancreatic masses, most of the lesions were hypodense (71lesions). Detailed evaluation by CT angiography showed that the hepatic artery was involved in 35 cases, the SMA in 49 cases, the celiac trunk in 29 cases and the gartroduodenal artery in 47 cases. There was no arterial vascular involvement in 25 cases. Finally as regards the anatomical variations; accessory right hepatic artery was detected in 11 cases, Accessory left hepatic artery in 12 cases, replaced left hepatic artery in 14 cases, replaced right hepatic artery in 10 cases, replaced common hepatic artery in 9 cases and 23 cases showed no anatomical variants. Conclusion: Multidetector CT with CT angiography plays a major role in the diagnosis and staging of pancreatic carci-noma. The use of standardized technique and radiologic reporting method can improve the evaluation of the tumor-vessel relationship and precisely evaluate the arterial anatom-ical variants.

Laparoscopic liver resection of the spiegel lobe by a lef-sidad approach preserving an accessory left hepatic artery

Presenter: Víctor Molina | Hospital de la Santa Creu i Sant Pau Background: Caudate lobe of the liver can be divided in three portions: Spiegel lobe, para-caval portion and caudate process . The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery. For that reason the Iwate criteria proposed to classify this surgery at the “2nd International Consensus Conference on Laparoscopic Liver Resection” as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor . For tumors located in the Spiegel lobe, the left side approach is preferred Methods: We present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma. A Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. Results: The patient was positioned in supine position. Six ports were used, 4 of 12mm and 2 of 5mm. We started the surgery with the left lateral segment mobilization. The gastrohepatic ligament was opened to expose the caudate lobe. In this case we only opened part of the ligament to preserve the accessory left hepatic artery. We continued retracting to the right the hepatic hilium with tissue band used as the external Pringle tourniquet to expose de caudate process and the right side of the Spiegel lobe. The transection of the liver was started with Thunderbeat and ultrasonic dissector. The portal branches to the Spiegel lobe were dissected and controlled with clips. We continued with the blunt dissection of the Spiegel lobe from the inferior vena cava. The fibrous ligament of the Spigel lobe to the crus of the diaphragm was cut and the retrocaudate vessels to the inferior vena cava were individualized and ligated with clips. Finally, we opened the gastrohepatic ligament behind the artery, pulled up the caudate lobe, and finished the liver transection. A closed aspirative drainage was left in place. The specimen was removed from an enlargement of the left subcostal 12mm port. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complications. Conclusion: Laparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.

Anatomy of the vasculature supplying hepatobiliary structures and celiac trunk branching patterns in the Thai population

Abstract Background Knowledge of the anatomy of the celiac trunk (CT) and arterial supply of the hepatobiliary system is essential for surgical and interventional radiological treatment of upper abdominal diseases. Objectives To determine the branching patterns of the CT and variation in origin and type of the right hepatic artery (RHA), left hepatic artery (LHA), and cystic artery (CA). Methods The anatomy of the CT in 100 cadavers from Thai adult donors was observed in 3 aspects: its branching pattern, the origin of the RHA and LHA, and the origin of the CA and its relation to the common bile duct (CBD) and common hepatic duct (CHD). Results The majority of the CT branching pattern was categorized as the type II classical pattern, which has 3 branches: the left gastric artery (LGA), splenic artery (SA), and common hepatic artery (CHA). The RHA branched from proper hepatic artery in 67 cadavers. The origin of the accessory RHA was either from the abdominal aorta or superior mesenteric artery (SMA), whereas the replaced RHA originated from the CHA, SMA, or CT. The accessory LHA ramified from CHA (2 cases) and LGA (1 case). The replaced LHA was found in 30 cadavers and 29 arose from the CHA. The single and double types of CA were found in 94 and 4 cadavers, respectively. In all, 57% of single CA passed posteriorly and 39% passed anteriorly to the CBD and CHD. Conclusions To lower posttreatment complications, variations in the anatomy and the vascular supply of hepatobiliary structures should be considered.

An accessory right hepatic artery derived from the superior mesenteric artery for anterior right liver lobe supply: a case report

PurposeDuring the last decades, it has been established that there are numerous individual anatomical variations of the arterial blood supply in human liver. In the present study, we examined the liver vascularization of an intrahepatic cholangiocarcinoma patient.MethodsFor surgical planning, an enhanced CT scan was performed and a three-dimensional model of liver vascularization constructed.ResultsThe patient was diagnosed as a Michel’s type VII hepatic artery variation. An accessory right hepatic artery arose from the superior mesenteric artery and had distributed into the right anterior liver to provide the blood supply of segments V and VIII, which was more medial than the territory of the right hepatic artery coming from the proper hepatic artery. At the same time, an accessory left hepatic artery originated from the left gastric artery.ConclusionWe present a case in which an accessory right hepatic artery provided a territory more medial than a right hepatic artery coming from the proper right artery.

Replaced gastroduodenal artery with continuation as accessory left hepatic artery: a rare anatomical variant

BackgroundPresented here is a rare case of a gastroduodenal artery (GDA) replaced to the superior mesenteric artery with continuation into an accessory left hepatic artery. To the authors’ knowledge, this rare anomaly is not described previously. Replaced GDA is reported, however without continuation into an accessory LHA.Case presentationA 74-year-old male with recurrent peptic ulcer disease presented with acute onset melena. This anomaly was discovered during abdominal angiography performed for treatment of a hemorrhagic duodenal ulcer. Initial celiac and common hepatic artery (CHA) subselection and angiography demonstrated no branch vessels. Angiography via the superior mesenteric artery demonstrated free extravasation into the duodenum and distal perfusion of the left hepatic lobe.ConclusionsThis is a rare variant of hepatic arterial anatomy. Importantly, this variant challenges a previously described anatomical model that attempts to explain observed CHA variation.

Computed Tomography Evaluation of the Arterial Supply to Segment 4 of the Liver.

Introduction:In a setting of living-donor liver transplant and patients undergoing extended hepatic resections for both primary and metastatic liver tumors, preoperative assessment of hepatic arterial anatomy is very important because of the risk of ischemic complications in the event of inadvertent injury to the arterial supply. Anatomical variations in hepatic arterial supply to the liver are very common and seen in nearly half the population. Identifying anomalous origin of segment 4 hepatic artery is vital since this vessel can cross the transection plane and can result in liver ischemia and liver failure. The purpose of our study is to study the variations in hepatic arterial anatomy to segment 4 of the liver in the Indian population.Materials and Methods:A retrospective evaluation of 637 consecutive computed tomography (CT) angiograms over a period of 1 year was performed, and we analyzed the arterial supply to segment 4 of the liver.Results:We found that the arterial supply to segment 4 of the liver originated from left hepatic artery (LHA) in majority of cases, 76.3%. LHA along with the accessory LHA supplied this segment in 6.4%, whereas the accessory LHA solely supplied this segment in 0.4%. The right hepatic artery (RHA) was seen to supply this segment in 10.2%. Dual supply with branches from the RHA and LHA was seen in 6.6% of patients.Conclusion:Preoperative mapping of segment 4 hepatic arterial supply using CT angiography will act as a roadmap to surgeons as they attempt to carefully dissect and preserve this segments' arterial supply. Depending on the anatomical variation, surgical techniques will vary to ensure safety of segment 4 arterial supply.