J Korean Surg Soc.  2009 Feb;76(2):100-108. 10.4174/jkss.2009.76.2.100.

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

• Yang SH
• Yin YH
• Jang JY
• Lee SE
• Chung JW
• Suh KS
• Lee KU
• Kim SW

• KMID: 2211265
• DOI: http://doi.org/10.4174/jkss.2009.76.2.100

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.

Keyword

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

MeSH Terms

Aorta
Arteries
Axis, Cervical Vertebra
Hepatic Artery
Mesenteric Artery, Superior

Figure

• 

  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).

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

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  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).

Reference

1. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg. 1966. 112:337–347.

2. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg. 1994. 220:50–52.

3. 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.

4. 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.

5. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE. Gray's Anatomy: The Anatomical Basis of Medicine and Surgery. 1995. 38th ed. London: Churchill Livingstone;3181548–1553.

6. 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.

7. Tandler J. über die Varietäten der Arteria coeliaca und deren Entwickelung. Anat Hefte. 1904. 25:473–500.

8. Blumgart LH. Surgery of the Liver, Biliary Tract, and Pancreas. 2007. 4th ed. Philadelphia: W.B. Saunders;20.

9. 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.

10. 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.

11. 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.

12. Adachi B. Das Arteriensystem Der Japaner. 2. Aorta Thoracalis - Arcus Plantaris Profundus. 1928. Kyoto: Maruzen co.;11–129.

13. Rigaud A, Cabanie H, Dejussieu J. Artere hepatique commune naissant en entier de la coronaire stomachique. Arch D'Anat Path. 1961. 9:151–152.

14. Kayaalp C, Nessar G, Kaman S, Akoglu M. Right liver necrosis: complication of laparoscopic cholecystectomy. Hepatogastroenterology. 2001. 48:1727–1729.

15. 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.

16. Charnsangavej C, Chuang VP, Wallace S, Soo CS, Bowers T. Angiographic classification of hepatic arterial collaterals. Radiology. 1982. 144:485–494.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. Sarmiento JM, Panneton JM, Nagorney DM. Reconstruction of the hepatic artery using the gastroduodenal artery. Am J Surg. 2003. 185:386–387.