Open Access, Peer-reviewed
pISSN 2288-6575
eISSN 2288-6796
    J Korean Surg Soc. 2009 Feb;76(2):100-108. Korean.
    Published online Feb 28, 2009.
    https://doi.org/10.4174/jkss.2009.76.2.100
    Copyright © 2009 The Korean Surgical Society
    Original Article

    Establishment of a Guideline for the Safe Management of Anatomical Hepatic Artery Variations While Performing Major Hepato-pancreatico-biliary Surgery

    Sung Hoon Yang, M.D., Ph.D., Yong Hu Yin, M.D.,2 Jin-Young Jang, M.D., Ph.D.,1 Seung Eun Lee, M.D.,1 Jin Wook Chung, M.D., Ph.D.,2 Kyung-Suk Suh, M.D., Ph.D.,1 Kuhn Uk Lee, M.D., Ph.D.,1 and Sun-Whe Kim, M.D., Ph.D.1
      • Department of Surgery, Incheon Medical Center, Incheon, Korea.
      • 1Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
      • 2Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
    Received October 13, 2008; Accepted November 03, 2008.

    Abstract

    Purpose

    Hepato-pancreatico-biliary (HPB) surgeons often must make decisions regarding hepatic artery (HA) resection while performing major HPB surgery. The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during major HPB surgery and to develop a useful algorithm in dealing with these needs.

    Methods

    We reviewed 1,324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in major HPB surgery. In reviewing our series and previous studies, we have created a set of guidelines that enables a pragmatic approach to the unique variations in HA and the risks of cancer invasion.

    Results

    Challenging HA variations during major HPB surgery were found in 25.7% of the cases and included variations of common HA from superior mesenteric artery (SMA), gastroduodenal artery (GDA), aorta, celiaco-mesenteric (CM) trunk or left gastric artery (LGA) (3.70%), the variations of the right HA from SMA, GDA, aorta, celiac axis (CA) including CM trunk or LGA (12.76%), the variations of the left HA from LGA, CA or GDA (4.46%), and the mixed types of the aberrant left medial HA and/or left lateral HA and/or right anterior HA and/or right posterior HA (2.11%).

    Conclusion

    Surgeons should have knowledge of the anatomically variable vasculature of the HA when planning for major HPB surgery. Preoperative imaging studies can aid and should be performed in anticipation of potential HA variations during major HPB surgery.

    Keywords
    Hepatic artery; Anatomical variations; Hepato-pancreatico-biliary surgery

    Figures

    Fig. 1
    Some challenging variations of HA in performing hepato-pancreatico-biliary surgery in 1,324 cases (RHA = Right hepatic artery; LHA = Left hepatic artery; GDA = Gastroduodenal artery; SMA = Superior mesenteric artery; LGA = Left gastric artery; SpA = Splenic artery; S = Segment of liver according to Couinaud's classification).

    Fig. 2
    Common hepatic artery arising from the superior mesenteric artery in 1,324 cases (*= Right gastroepiploic artery, †= Gastroduodenal artery).

    Fig. 3
    Some challenging variations of the HA to 4 sections of the liver in performing the hepato-pancreatico-biliary surgery in 1,324 cases (RHA = Right hepatic artery; LHA = Left hepatic artery; RA = Right anterior hepatic artery; RP = Right posterior hepatic artery; LM = Left medial hepatic artery; LL = Left lateral hepatic artery; GDA = Gastroduodenal artery; SMA = Superior mesenteric artery; LGA = Left gastric artery; SpA = Splenic artery; S = Segment of liver according to Couinaud's classification).

    Fig. 4
    Algorithm for dealing with HA that has the problems of preservation in performing hepato-pancreatico-biliary surgery (HA = hepatic artery).

    Tables

    Table 1
    Summary of the challenging HA variations to be recognized while performing major hepatectomy or pancreatoduodenectomy

    References

      1. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg 1966;112:337–347.
      1. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg 1994;220:50–52.
      1. Koops A, Wojciechowski B, Broering DC, Adam G, Krupski-Berdien G. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat 2004;26:239–244.
      1. Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Brown KT. Variant hepatic arterial anatomy revisited: digital subtraction angiography performed in 600 patients. Radiology 2002;224:542–547.
      1. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE. In: Gray's Anatomy: The Anatomical Basis of Medicine and Surgery. 38th ed. London: Churchill Livingstone; 1995. pp. 318pp. 1548-1553.
      1. Kosaka M, Horiuchi K, Nishida K, Taguchi T, Murakami T, Ohtsuka A. Hepatopancreatic arterial ring: bilateral symmetric typology in human celiaco-mesenteric arterial system. Acta Med Okayama 2002;56:245–253.
      1. Tandler J. über die Varietäten der Arteria coeliaca und deren Entwickelung. Anat Hefte 1904;25:473–500.
      1. Blumgart LH. In: Surgery of the Liver, Biliary Tract, and Pancreas. 4th ed. Philadelphia: W.B. Saunders; 2007. pp. 20.
      1. Uva P, Arvelakis A, Rodriguez-Laiz G, Lerner S, Emre S, Gondolesi G. Common hepatic artery arising from the left gastric artery: a rare anatomic variation identified on a cadaveric liver donor. Surg Radiol Anat 2007;29:93–95.
      1. Kobayashi S, Matsui O, Kadoya M, Gabata T, Sanada J, Terayama N. Right posterior-superior subsegmental hepatic artery originating from the right inferior adrenal artery. Cardiovasc Intervent Radiol 2001;24:271–273.
      1. Wang K, Hu S, Jiang X, Zhu M, Jin B. Liver transplantation for patient with variant hepatic artery arising from right renal artery: a case report. Transplant Proc 2007;39:1716–1717.
      1. Adachi B. In: Das Arteriensystem Der Japaner. 2. Aorta Thoracalis - Arcus Plantaris Profundus. Kyoto: Maruzen co.; 1928. pp. 11-129.
      1. Rigaud A, Cabanie H, Dejussieu J. Artere hepatique commune naissant en entier de la coronaire stomachique. Arch D'Anat Path 1961;9:151–152.
      1. Kayaalp C, Nessar G, Kaman S, Akoglu M. Right liver necrosis: complication of laparoscopic cholecystectomy. Hepatogastroenterology 2001;48:1727–1729.
      1. Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Yoshidome H, et al. Unilateral hepatic artery reconstruction is unnecessary in biliary tract carcinomas involving lobar hepatic artery: implications of interlobar hepatic artery and its preservation. Hepatogastroenterology 2000;47:1526–1530.
      1. Charnsangavej C, Chuang VP, Wallace S, Soo CS, Bowers T. Angiographic classification of hepatic arterial collaterals. Radiology 1982;144:485–494.
      1. Vellar ID. The blood supply of the biliary ductal system and its relevance to vasculobiliary injuries following cholecystectomy. Aust N Z J Surg 1999;69:816–820.
      1. Alves A, Farges O, Nicolet J, Watrin T, Sauvanet A, Belghiti J. Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg 2003;238:93–96.
      1. Yang SH, Yin YH, Jang JY, Lee SE, Chung JW, Suh KS, et al. Assessment of hepatic arterial anatomy in keeping with preservation of the vasculature while performing pancreatoduodenectomy: an opinion. World J Surg 2007;31:2384–2391.
      1. Smith GS, Birnbaum BA, Jacobs JE. Hepatic infarction secondary to arterial insufficiency in native livers: CT findings in 10 patients. Radiology 1998;208:223–229.
      1. Kishi Y, Sugawara Y, Kaneko J, Akamatsu N, Imamura H, Asato H, et al. Hepatic arterial anatomy for right liver procurement from living donors. Liver Transpl 2004;10:129–133.
      1. Yamamoto S, Kubota K, Rokkaku K, Nemoto T, Sakuma A. Disposal of replaced common hepatic artery coursing within the pancreas during pancreatoduodenectomy: report of a case. Surg Today 2005;35:984–987.
      1. Miyamoto N, Kodama Y, Endo H, Shimizu T, Miyasaka K, Tanaka E, et al. Embolization of the replaced common hepatic artery before surgery for pancreatic head cancer: report of a case. Surg Today 2004;34:619–622.
      1. Kondo S, Katoh H, Shimizu T, Omi M, Hirano S, Ambo Y, et al. Preoperative embolization of the common hepatic artery in preparation for radical pancreatectomy for pancreas body cancer. Hepatogastroenterology 2000;47:1447–1449.
      1. Nakano H, Kikuchi K, Seta S, Katayama M, Horikoshi K, Yamamura T, et al. A patient undergoing pancreaticoduodenectomy in whom involved common hepatic artery anomalously arising from the superior mesenteric artery was removed and reconstructed. Hepatogastroenterology 2005;52:1883–1885.
      1. Li B, Chen FZ, Ge XH, Cai MZ, Jiang JS, Li JP, et al. Pancreatoduodenectomy with vascular reconstruction in treating carcinoma of the pancreatic head. Hepatobiliary Pancreat Dis Int 2004;3:612–615.
      1. Settmacher U, Langrehr JM, Husmann I, Eisele R, Bahra M, Heise M, et al. Reconstruction of visceral arteries with homografts in excision of the pancreas. Chirurg 2004;75:1199–1206.
      1. Endo I, Masunari H, Sugita M, Morioka D, Tanaka K, Togo S, et al. Indications for combined resection and reconstruction of the hepatic artery in biliary tract carcinoma. Nippon Geka Gakkai Zasshi 2001;102:820–825.
      1. Kondo S, Ambo Y, Katoh H, Hirano S, Tanaka E, Okushiba S, et al. Middle colic artery-gastroepiploic artery bypass for compromised collateral flow in distal pancreatectomy with celiac artery resection. Hepatogastroenterology 2003;50:305–307.
      1. Sarmiento JM, Panneton JM, Nagorney DM. Reconstruction of the hepatic artery using the gastroduodenal artery. Am J Surg 2003;185:386–387.
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    MeSH Terms
    Aorta
    Arteries
    Axis, Cervical Vertebra
    Hepatic Artery
    Mesenteric Artery, Superior
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