Preserving a Rare Type of Variant Right Hepatic Artery Combines Surgical Radicality and Intact Liver Perfusion during Pancreatectomy

Abstract

An anomalous anatomy of the celiac trunk, and particularly of the right hepatic artery, may have a significant impact on major hepatobiliary and pancreatic surgery. According to some authors, every third patient has an aberrant right hepatic artery. We present a very rare case of replaced right hepatic artery (RRHA) arising from the gastroduodenal artery associated with an accessory left hepatic artery originating from the left gastric artery in a 54-year-old woman with a pancreatic head carcinoma. The patient underwent total pancreatectomy on account of a soft lipomatous pancreas with heterogeneous changes of the pancreatic body and tail. We preserved the RRHA and achieved R0 resection margins. Preoperative evaluation of CT angiograms, an awareness of any anomalous arterial anatomy of the upper abdomen, and a meticulous surgical technique are the key to performing oncologically radical surgery without threatening the arterial liver supply.

Replaced Segment 6 Artery From the Gastroduodenal Artery: A Challenging and Rare Anatomical Variation of Hepatic Artery in Pancreaticoduodenectomy

“…Neoadjuvant chemotherapy to reduce the size of the tumor and to attempt preservation of the artery [ 16 , 17 ]. Deep knowledge of hepatic arterial anatomy is paramount in performing oncological radical procedures to achieve R0 resection without hindering a safe operation [ 18 ].…”

Replaced right hepatic artery passing anterior to pancreas: a rare and challenging anatomical variant during pancreaticoduodenectomy

“…Angiography can provide important details about aberrant vessels, but it does not provide details about relationship between the paths of the arteries and the pancreatic parenchyma, which is important information during presurgical planning. Hence contrast enhanced computed tomography with angiography becomes necessary in preoperative planning [11]. In major hepatobiliary and pancreatic surgery, various strategies have been described to manage an aberrant RHA: (1) resection versus preservation/reconstruction depending on whether the aberrant RHA is accessory or replaced, as well as depending on course of the artery in relation to pancreatic head and depending on whether the tumor infiltrates the vessel; (2) preoperative embolization; (3) temporary clamping and confirmation collateral circulation before ligation if discovered intraoperatively; and (4) neoadjuvant chemotherapy and reassessment [15,18,19].…”

“…The presence of above anatomical variations may increase the risk of complications through direct (bleeding due to iatrogenic intraoperative vessel injury) or indirect (postoperative ischemia of tissues and anastomotic leakage) mechanisms. Preoperative contrast-enhanced computerized tomography (CECT) scans are useful in guiding the surgeon throughout the PD surgery and reducing the risk of intra/postoperative complications [11]. In this paper, we present a very rare case of replaced right hepatic artery arising from the superior mesenteric artery coursing anterior to pancreatic head associated with replaced left hepatic artery originating from the left gastric artery.…”