ARTERY FIRST TECHNIQUE FOR MANAGEMENT OF ABERRANT HEPATIC ARTERIAL ANATOMY DURING PANCREATICODUODENECTOMY-EXPERIENCE FROM A SPECIALIZED HEPATO-PANCREATO-BILIARY UNIT

Purpose: Aberrant hepatic arterial anatomy poses a challenge for surgeon during pancreaticoduodenectomy (PD). These anomalies are best picked up on pre-operative imaging to avoid inadvertent injury to the aberrant vasculature resulting in liver ischaemia or biliary-enteric anastomotic failure. We present our experience of dealing with aberrant hepatic vessels during PD. Methods: Patients with aberrant hepatic vasculature who underwent PD between September 2014 and August 2015 were included in the study. We used artery rst technique for dissection in cases identified on pre operative imaging. Aberrations were classed according to Hiatt classi cation. Results: A total of 23 PD were performed with aberrant arterial anatomy in 10 (43%) cases. These vessels were recognised and preserved in nine cases. In one patient, the replaced right hepatic artery (RRHA) arising from superior mesenteric artery (SMA) was coursing through pancreatic parenchyma needing resection and reconstruction with uneventful post-operative recovery. We also identified one RRHA arising from SMA coursing lateral to common bile duct and entering liver parenchyma in gallbladder fossa. Conclusion: Aberrant hepatic arterial anomalies are common and should ideally be picked up by pre-operative imaging. It is possible to preserve these vessels in most cases with careful surgical dissection using artery first technique. Surgeons performing PD should be well versed with the aberrant vascular anatomy to minimise any inadvertent damage. Key words: Aberrant hepatic artery, artery first technique, pancreaticoduodenectomy

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Replaced right hepatic artery arising from the gastroduodenal artery: a rare and challenging anatomical variant of the Whipple procedure

Journal of Surgical Case Reports ◽

10.1093/jscr/rjaa136 ◽

2020 ◽

Vol 2020 (6) ◽

Author(s):

Eva María Pueyo-Périz ◽

Patricia Sánchez-Velázquez ◽

Maite De Miguel ◽

Aleksandar Radosevic ◽

Henrik Petrowsky ◽

...

Keyword(s):

Hepatic Artery ◽

Vascular Anatomy ◽

Anatomical Variations ◽

Arterial Injury ◽

Whipple Procedure ◽

Gastroduodenal Artery ◽

Irreversible Damage ◽

Anatomical Variant ◽

Right Hepatic Artery ◽

Replaced Right Hepatic Artery

Abstract Accurate assessment of the vascular anatomy is a prerequisite of any pancreatic resection, since an unnoticed arterial injury in the context of a complex resection such as Whipple procedure, can seriously jeopardize patient’s safety. This article aims to describe an infrequent anatomic variant of a replaced right hepatic artery originating directly from the gastroduodenal artery and its potential implications for duodenopancreatectomy, as the gastroduodenal artery is routinely divided. We present here two different cases of this arterial abnormality identified during a Whipple procedure and its implications in each different setting. Preoperative identification of anatomical variations is essential for proficient surgical planning. Nevertheless, when detected during surgery, an meticulous dissection of the hepatoduodenal ligament is required to identify all the vascular relations in order to avoid irreversible damage.

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Multi-detector CT in the pre-operative assessment of live donors for liver transplantation

International Surgery Journal ◽

10.18203/2349-2902.isj20172101 ◽

2017 ◽

Vol 4 (6) ◽

pp. 1930

Author(s):

Vandana Gupta ◽

Pallavi C. J. ◽

Arjun Kalyanpur ◽

Dayananda L.

Keyword(s):

Liver Transplantation ◽

Multidetector Ct ◽

Imaging Modality ◽

Vascular Anatomy ◽

Liver Parenchyma ◽

Correlation Study ◽

Donor Liver Transplantation ◽

Live Donors ◽

Living Related ◽

Operative Assessment

Background: Transplantation surgeons are now performing living donor liver transplantation because of the severe shortage of cadaveric livers. This study was undertaken to assess the role of 64-slice multidetector CT in the pre op evaluation of living related liver donors for transplantation.Methods: This was a prospective correlation study of 26 patients who were referred to the Department of Radiodiagnosis, Narayana Hrudayalaya, Bangalore for evaluation of living related donors for liver transplantation from March 2008 to May 2009.Results: MDCT has 100% sensitivity, 93.7% specificity in detecting the hepatic arterial anatomy; 100% sensitivity and specificity in detecting portal venous anatomy and its variants, and 93.3% sensitivity and 100% specificity in detecting hepatic venous anatomy.Conclusions: Multi-detector CT is a single comprehensive, non-invasive and accurate imaging modality for pre-operative and postoperative evaluation of liver transplant patient. It allows an accurate assessment of liver parenchyma, hepatic vascular anatomy, graft volume and detection of post-operative complications in donors and recipients of LRLT.

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Normal Vascular Anatomy: Normal Arterial Anatomy

Imaging of the Temporal Bone ◽

10.1055/b-0034-87727 ◽

2009 ◽

Keyword(s):

Vascular Anatomy ◽

Arterial Anatomy

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Virtual non-contrast for evaluation of liver parenchyma and vessels: results from 25 patients using multi-phase spectral-detector CT

Acta Radiologica ◽

10.1177/0284185119893094 ◽

2019 ◽

Vol 61 (8) ◽

pp. 1143-1152 ◽

Cited By ~ 3

Author(s):

Kai Roman Laukamp ◽

Vivian Ho ◽

Verena Carola Obmann ◽

Karin Herrmann ◽

Amit Gupta ◽

...

Keyword(s):

Portal Vein ◽

Hepatic Artery ◽

Abdominal Aorta ◽

Liver Parenchyma ◽

Image Noise ◽

Common Hepatic Artery ◽

Diagnostic Assessment ◽

Arterial Phase ◽

Spectral Detector Ct ◽

Venous Phase

Background In abdominal imaging, contrast-enhanced computed tomography (CT) examinations are most commonly applied; however, unenhanced examinations are still needed for several clinical questions but require additional scanning and radiation exposure. Purpose To evaluate accuracy of virtual non-contrast (VNC) from arterial and venous phase spectral-detector CT (SDCT) scans compared to true-unenhanced (TNC) images for the evaluation of liver parenchyma and vessels. Material and Methods A total of 25 patients undergoing triphasic SDCT examinations were included. VNC was reconstructed from arterial and venous phases and compared to TNC images. Quantitative image analysis was performed by region of interest (ROI)-based assessment of mean and SD of attenuation (HU) in each liver segment, spleen, portal vein, common hepatic artery, and abdominal aorta. Subjectively, iodine subtraction and diagnostic assessment were rated on 5-point Likert scales. Results Attenuation and image noise measured in the liver from VNC were not significantly different from TNC (TNC: 54.6 ± 10.8 HU, VNC arterial phase: 55.7 ± 10.8 HU; VNC venous phase: 58.3 ± 10.0 HU; P > 0.05). VNC also showed accurate results regarding attenuation and image noise for spleen, portal vein, and abdominal aorta. Only iodine subtraction in the common hepatic artery in the arterial phase was insufficient which was confirmed by the subjective reading. Apart from that, subjective reading showed accurate iodine subtraction and comparable diagnostic assessment. Conclusion VNC from the arterial and venous phases were very similar to TNC yielding mostly negligible differences in attenuation, image noise, and diagnostic utility. Inadequate iodine subtraction occurred in hepatic arteries in the arterial phase.

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Effect of Repeated Normothermic Ischaemia on Normal Liver Parenchyma

Acta Radiologica ◽

10.1177/028418518702800217 ◽

1987 ◽

Vol 28 (2) ◽

pp. 215-219

Author(s):

H. Stridbeck ◽

T. Holmin ◽

I. Hägerstrand

Keyword(s):

Portal Vein ◽

Hepatic Artery ◽

Alternative Treatment ◽

Balloon Catheter ◽

Normal Liver ◽

Liver Parenchyma ◽

Histopathologic Examination ◽

Liver Tumours ◽

Small Areas ◽

Minimal Damage

Hepatic ischaemia was induced in 8 mesenterico-cavally shunted pigs. The hepatic artery was occluded with biodegradable starch microspheres and the portal vein with a balloon catheter. The liver was kept ischaemic for 90 minutes at the beginning, and 90 minutes at the end, of a 24-hour period. At histopathologic examination 6 of the livers had multiple, small areas of necrosis. The total volume of these necroses accounted for no more than 10 to 15 per cent of each liver. No necrosis was evident in 2 livers. Thus normothermic Ischaemia for 2 periods of 90 minutes each within a 24-hour period caused minimal damage to the liver. An alternative treatment in patients with liver tumours could therefore be simultaneous occlusion of the hepatic artery and the portal vein.

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Outcome of concomitant resection of the replaced right hepatic artery in pancreaticoduodenectomy without reconstruction

Langenbeck s Archives of Surgery ◽

10.1007/s00423-018-1650-9 ◽

2018 ◽

Cited By ~ 1

Author(s):

Toshimichi Asano ◽

Toru Nakamura ◽

Takehiro Noji ◽

Keisuke Okamura ◽

Takahiro Tsuchikawa ◽

...

Keyword(s):

Hepatic Artery ◽

Right Hepatic Artery ◽

Replaced Right Hepatic Artery

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Rare Hepatic Arterial Anatomic Variants in Patients Requiring Pancreatoduodenectomy and Review of the Literature

Case Reports in Surgery ◽

10.1155/2012/953195 ◽

2012 ◽

Vol 2012 ◽

pp. 1-3

Author(s):

Smita Ramanadham ◽

Seth M. Toomay ◽

Adam C. Yopp ◽

Glen C. Balch ◽

Rohit Sharma ◽

...

Keyword(s):

Uncinate Process ◽

Arterial System ◽

Cross Sectional ◽

Replaced Right Hepatic Artery ◽

Contrast Enhanced ◽

Cross Sectional Imaging ◽

Head Of The Pancreas ◽

Anatomic Variants ◽

Hepatobiliary And Pancreatic Surgery ◽

Arterial Anatomy

Normal hepatic arterial anatomy occurs in approximately 50–80% of cases; for the remaining cases, multiple variations have been described. Knowledge of these anomalies is especially important in hepatobiliary and pancreatic surgery in order to avoid unnecessary complications. We describe two cases of patients undergoing pancreatoduodenectomy for abnormalities in the head of the pancreas. Preoperative contrast-enhanced cross-sectional imaging demonstrated relevant, rare hepatic arterial variants: (1) a completely replaced hepatic arterial system with a gastroduodenal artery (GDA) arising directly from the celiac axis and (2) a replaced right hepatic artery originating from the superior mesenteric artery and traveling anterior to the pancreatic uncinate process and head. These findings were confirmed during pancreatoduodenectomy. Both of these variants have been rarely described with an incidence of <1.0%. In the present paper, we describe the hepatic arterial anomalies commonly encountered and clarify the important details associated with these variants as they pertain to pancreatoduodenectomy.

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