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Appreciation of the potential anatomical variation of the hepatic arterial supply and branches of the abdominal aorta is of paramount importance in pancreatic and hepatobiliary surgery. Here we describe a hitherto un-reported coelio-mesenteric anastomotic connection between a replaced right hepatic artery, originating from the superior mesenteric artery, and the left hepatic branch of the proper hepatic artery. The embryological origins of the variant anatomy as well as its potential surgical implications are discussed with a view to encourage thorough pre-operative interrogation of available imaging by radiologists and surgeons to successfully identify such variants and take advantage of their potentially useful functionality.

To describe a previously unreported anatomical variant of the hepatic arterial supply: a conjoined right hepatic artery, formed by branches of the common hepatic artery and gastroduodenal artery. A 54-year-old female with oligometastatic colorectal cancer with metastases to the liver presented for planning stage arteriography in preparation for Y90 radioembolization. Arteriography of the common hepatic artery demonstrated bifurcation into a right hepatic artery and gastroduodenal artery. The gastroduodenal artery gave rise to a proximal branch, from which the left hepatic artery originated and then continued to anastomose in the hilum of the liver to the right hepatic artery originating from the common hepatic artery. It was initially identified on visceral artery arteriography and then retrospectively recognized on pre-procedural CT scan. Anatomical variants of the hepatic arterial supply are important to recognize during planning stage arteriography in preparation for Y90 radioembolization. Knowledge of these variants is also important for pre-operative planning.

Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

The aim of the present study was to identify the hepatic vascular variations with visual three-dimensional (3D) reconstruction of vessels in pediatric patients with choledochal cyst (CDC). We retrospectively analyzed the data of 84 children with pathologically confirmed CDCs treated in the Children's Hospital of Soochow University. 180 patients without CDCs as a control to analysis the hepatic artery and portal vein anatomy. All patients were examined by multi-slice spiral CT (MSCT) and the images of children with CDC were reconstructed by Hisense computer-assisted surgery system (Hisense CAS) to obtain visual 3D images. There were 71 females and 13 males diagnosed with CDC. According to Todani classification of CDC, there were 42 cases of type Ia, 10 cases of type Ic and 32 cases of type IVa. There were 10 (11.9%) patients with hepatic artery variations, 14 (16.7%) patients with right hepatic artery located on the ventral side of the CDC, and 16 (19.0%) patients with portal vein variations. Sex, age and types of the cyst were not associated with the presence of vascular variations. There was no significant difference in hepatic vascular variation between CDCs and control groups. Visual 3D images clearly displayed the hepatic vascular variations and the spatial structure of the CDC in pediatric patients with CDC. Hepatic artery and portal vein variations can be detected in pediatric patients with CDC. Visual 3D technique can visually and stereoscopically display the anatomical variations of the hepatic artery and portal vein.

Perineural invasion (PN) is often found in perihilar cholangiocarcinoma. New procedure was developed to assess PN around the right hepatic artery (RHA) using dual-energy computed tomography (DECT). Thirty patients with perihilar cholangiocarcinoma who underwent DECT before biliary drainage were retrospectively reviewed. Mask images, i.e., the periarterial layer (PAL) around the RHA and superior mesenteric artery (SMA), were made from late arterial phase DECT. The mean CT number of the PAL was measured. Twenty patients with PN around the RHA were classified into the PN (+) group. The remaining 10 patients without PN and other 26 patients with other diseases that are never accompanied with PN were classified into the PN (−) group. The PAL ratio (the CT number of the PAL around the RHA relative to that around the SMA) was calculated. Both the mean CT number of the PAL around the RHA and the PAL ratio were significantly higher in the PN (+) group than in the PN (−) group. According to an ROC analysis, the predictive ability of the PAL ratio was superior. Using the cutoff value of the PAL ratio 1.009, a diagnosis of PN around the RHA was made with approximately 75% accuracy. Assessment with CT number of the PAL reconstructed from DECT images is an easy and objective method to diagnose PN.

Variations in the hepatic artery are commonly described in the literature, which is vital for the success procedure of all hepatobiliary surgery. Usually a variation occurs in either the accessory right hepatic artery (aRHA) or the accessory left hepatic artery (aLHA). However, we report an extremely rare case where the variation occurs in both simultaneously. We over served the aRHA arising from the gastroduodenal artery and branching into the superior pancreatic duodenum artery, while the aLHA arose from the common hepatic artery and branched into right gastric artery. This situation has never been reported in literature. We will discuss the meaning of this hepatic artery variation in a clinical setting.

Despite advantages of minimally invasive surgery, many hepatobiliary surgeons are hesitant to offer this approach for major hepatic resection due to concerns of difficulty in liver manipulation, bleeding control, and suboptimal oncologic outcomes. The robotic surgical system has revolutionized the way traditional laparoscopic liver resection is undertaken. Limitations of traditional laparoscopy are being resolved by robotic technology. We aimed to describe aspects of minimally invasive liver surgery and our standardized technical approach. We discussed technical aspects of performing robotic total right hepatic lobectomy and described our standardized institutional method. A 79-year-old man with an 11-cm biopsy-proven hepatocellular carcinoma was taken to the operating room for a robotic total right hepatic lobectomy. Past medical and surgical history was consistent with hypertension and diabetes mellitus. Robotic extrahepatic Glissonean pedicle approach was used to gain inflow vascular control. Right hepatic artery and portal vein were individually dissected and isolated prior to division. An intraoperative robotic ultrasound was utilized to guide liver parenchymal transection, securing negative margins. Robotic vessel sealing device was used as the main energy device during the parenchymal transection. Right hepatic vein was transected intrahepatically using a linear stapler. Operative time was 200 min without intraoperative complications. Estimated blood loss was 100 ml. Postsurgical recovery was uneventful and he was discharged home on postoperative day 4. Minimally invasive robotic total right hepatic lobectomy is feasible with excellent perioperative outcomes.

Purpose During 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. Methods For surgical planning, an enhanced CT scan was performed and a three-dimensional model of liver vascularization constructed. Results The 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. Conclusion We 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.

Moynihan’s or caterpillar hump of the right hepatic artery (RHA) is a rare anomaly in which it is tortuous and comes close to the gall bladder or cystic duct, the cystic artery being short most of the times. In such cases, the RHA is mistakenly identified as the cystic artery and is prone to be ligated or injured during cholecystectomy. Here, we report a case of cholelithiasis where, during laparoscopic cholecystectomy, Moynihan’s hump was encountered and tackled successfully. We also revisit the surgical significance of this anomaly and discuss how to deal with it safely.

The anatomy of hepatic arteries is one of the most variable. Accurate awareness of all the possible anatomic variations is crucial in the upper GI surgery and especially in liver and pancreas transplantation. The most frequent anatomical variants are: a replaced or accessory right hepatic artery (RHA) from the superior mesenteric artery (6.3-21 %), a replaced or accessory left hepatic artery (LHA) from the left gastric artery (LGA) (3-18 %) or a combination of these two variants (up to 7.4 %). Herein, we describe the case of a 67-year-old cadaveric organ donor who presented a RHA originating from the splenic artery (SA) associated with both a CHA originating from the celiac trunk (CT) and a LHA originating from the LGA.

Activity planning for (90)Y radioembolization aims to maximize the effect of the treatment while keeping toxicity acceptably low. Our aim was to describe the amount of residual activity in post-treatment v-vials and tubing and analyze the possible factors affecting it (total activity administered, number of split activity injection(s), previous treatments, administration artery and microcatheter size), as these may influence dosimetric planning and treatment.This was a retrospective review using case records of patients who received (90)Y-radioembolization for hepatic tumors at a single tertiary center. From August 2013 to September 2015, seventy-seven out of one hundred and fifty patients who received radioembolization with (90)Y resin microspheres due to inoperable Hepatocellular Carcinoma (HCC) or liver metastases were included. The rest were mainly excluded due to incomplete data sets. The number of split activities (injections) for the radioembolization could be: one single injection, two or three. The remnant activity in post-treatment v-vials and tubing were measured for every patient. The administration arteries evaluated were: proper hepatic artery (PHA), right hepatic artery (RHA), middle hepatic artery (MHA), left hepatic artery (LHA) and small caliber branch arteries. The sizes of the microcatheters (2.2 or 2.7 Fr) used to administer the dose were also evaluated.In total, 77 out of 150 patients were included in the final analysis. There were 59 men of median age 64.0 years old. The total median dose loss was 0.10 GBq. The total dose loss increased 0.244 GBq [95 % CI = (0.169, 0.318)] when three split activities were given compared to single activity injection. Activity loss for each injection increased 0.0297 GBq [95 % CI = (0.0151, 0.0443)] for every 1.0 GBq increase of split activity injection. There were no significant statistical differences in the rest of patient characteristics.There is significant loss of activity observed during radioembolization, which can have a major dosimetric impact. The total administered activity and the number of split injections during radioembolization are the main influencing factors. Further prospective studies as well as measures of clinical outcome are warranted.

Replaced right hepatic artery is a well-described normal anatomical variant, not previously associated with acute or chronic abdominal symptoms or long-term sequelae. We report a 15-year-old girl presenting with nearly a decade of symptoms secondary to external compression of the proximal duodenum by the ventral passage of a replaced right hepatic artery. Surgical bypass of the duodenal obstruction significantly improved her symptoms. Replaced right hepatic artery related duodenal compression should be considered in the differential diagnosis of proximal duodenal obstruction. The presence of the replaced right hepatic artery should be clearly communicated to allow optimal presurgical planning.

The aim of this study was to investigate whether individual arterial and portal venous division during hepatectomy is always safe by examining the presence of the anomalous arterial ramification in the right liver. The ramifications of the right hepatic artery (RHA) were investigated by three-dimensional (3D) reconstruction imaging using a computer software program in 87 patients undergoing computed tomography during angiography as a preoperative assessment of intrahepatic tumors. The anterior view showed that the RHA bifurcated into the anterior and posterior sector arteries at the hilum in 76 patients. Sector-intersecting arteries from the posterior to the anterior sector and vice versa were found in 7 and 4 of those patients, respectively. The RHA in the other 11 patients was divided in a complex manner into more than 2 arteries: e.g., the first branch to the cranial part of the posterior sector, the second to the anterior sector, and the third to the caudal part of the posterior sector. A total of 22 patients showed anomalous ramification of RHA. Preoperative observation of the hepatic artery by 3D imaging is very useful to detect anomalous ramification. Arterial dissection during the intrafascial approach should be cautiously performed based on the 3D images.

The aim of the study was to determine the impact of replaced or accessory right hepatic artery (RARHA) during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). Four hundred seventy-one consecutive patients underwent PD for PA at the two institutions; 47 patients (10%) had RARHA: 16 patients (neoRARHA group) received neoadjuvant chemoradiation, and 31 patients did not receive preoperative treatment (RARHA group). Thirty-one matched patients without RARHA comprised our control group. RARHA was preserved in 44 patients; three patients with involved RARHA had reconstruction (n = 2) or ligation (n = 1). Patients with R1 resection (n = 8) had tumor size ≥3 cm. Patients in the neoRARHA group had identical positive margin rate when compared with patients in RARHA group (p = 0.6). No difference was noted in median or 3-year overall survival times between RARHA group and control group. Two patients in RARHA group with involved RARHA died of disease progression after 6 and 12 months of follow-up. One patient in neoRARHA group with involved RARHA was still alive without recurrence after 28 months’ follow-up. Pathologic findings did not show increased positive margins despite preservation of RARHA. In contrast, patients with frank RARHA involvement seemed to have poor survival. Thus, patients with suspicion of involved RARHA should be considered for neoadjuvant chemoradiation.

The right hepatic artery usually branches from the common hepatic artery, however, there are cases showing anatomic variations. We present 41-year-old female patient with gallbladder cancer. In this case, the accessory right hepatic artery branched from the gastroduodenal artery, passed in front of the common bile duct and fed into the anterior segment of the liver. Cholecystectomy and resection of the extrahepatic bile duct with hepaticoenterostomy were performed successfully, preserving the accessory right hepatic artery. There are few reports presenting such an extremely rare anomaly of hepatic arteries in the English literature. Additionally, we herein present a review of the English literature regarding anatomic variations of right hepatic artery.

The aim of this study was to identify and to classify anatomical hepatic artery (HA) variations concerning 932 HA dissections in liver transplantation (LT). Normal HA distribution was found in 68.1%. Variations of HA were detected in 31.9% and were divided into three groups describing 48 common hepatic artery (CHA) anomalies, 236 left or right hepatic artery (RHA) anomalies and 13 rare variations including one case of RHA stemmed from the inferior mesenteric artery and one case of normal CHA passed behind the portal vein. The authors propose a modified classification for HA anomalies which are based on the origin of the hepatic arterial supply (either by the CHA as the only source of the arterial vascularization or by additional or replaced right and left arteries) in order to improve management of liver disease thus as in LT.

Accessory hepatic artery is an incidental finding during hepatobiliary, pancreatic surgery and may be found during hepatic transplantation surgery on angiogram. This artery should be carefully identifiedpreserved during these surgeries.A case of accessory right hepatic artery found incidentally during pancreatico duodenectomy [whippels procedure] identified, dissected carefullypreserved.Anomalous hepatic vasculature is a rare incidental finding during hepatobiliary-pancreatic surgery. These anomalies or accessory hepatic arteries should be identified, carefully preserved to prevent inadvertent injury, torrential bleedinghepatic necrosis .preservation of these anomalous vasculature will not compromise oncological margin.

A replaced right hepatic artery (rRHA) arising from the superior mesenteric artery and an interlobar parenchymal bridge over the sagittal fissure of liver have been observed on a 64 year old formalin-fixed male cadaver in the anatomy laboratory. As we followed a detailed segmental anatomy, encountered an arterial distribution on the segment IV featuring a different pattern from the literature so far. According to our observations, the segment I is supplied by both left (LHA) and middle (MHA) hepatic arteries; the segments II and III are supplied by the LHA while the segment IV is supplied by both the MHA and rRHA. The segments V-VIII are supplied only by the rRHA. Our case emphasizes the importance of arterial variations of liver once again in terms of the surgical procedures during the liver transplantation, hepatic tumors, and etc. Our discussion particularly focuses to the arterial supply of the segment IV and possible complications it may cause during/after the liver operations.

The goals of this study were to delineate the boundary between the right and left hepatic artery territories by computed tomography (CT), to compare this boundary with the middle scissura of Couinaud's segmental anatomy, and to discuss the clinical implications of these findings. The 18 patients who underwent transcatheter oily chemoembolization (TOCE) of liver tumors via the right or left hepatic artery, were examined with an immediate postembolization CT scan. We measured the orientation of the watershed line between the right and left hepatic artery territories and the orientation of the middle scissura on other available sectional imaging modalities, and then compared the middle scissura with the arterial watershed line. A part of segment IV was fed by the right hepatic artery in two of 18 (11.1%) patients. Moreover, one of 4 segment IV lesions was embolized via right hepatic artery infusion. Thus, in 11.1% of cases there was no coincidence between the arterial watershed line and the middle scissura. Some segment IV lesions may be fed and therefore embolized only via right hepatic artery infusion in TOCE for liver tumor.

The arterial anatomy supplying the liver is highly variable. One of the most common variants is a completely replaced right hepatic artery which is seen in about 11% of the population. Interruption of arterial flow to the right hepatic artery at the time of pancreaticoduodenectomy has been associated with biliary fistula and the consequent complications, as well as stenosis of the biliary enteric anastomosis. Malignancies of the posterior aspect of the head of the pancreas can encase a replaced right hepatic artery without involvement of other vascular structures. In this situation, it is possible to resect and reconstruct the replaced right hepatic artery to maintain oxygen delivery to the biliary enteric anastomosis. Herein we describe a technique to reconstruct a replaced right hepatic artery following resection of the vessel en bloc with the tumor during a pancreaticoduodenectomy, using inflow from the gastroduodenal artery.

To perform hepatic surgery a precise preoperative and intraoperative study of liver vascular supply is mandatory. Detecting vascular variations may have great importance on surgical strategy and outcome, and details of anatomy do not concern only academical knowledge but become deeply involved in practice. We present a case of unusual blood supply to the liver, the common hepatic artery was directed to the right liver and a right hepatic artery originating from the superior mesenteric artery was directed to the left liver. The right hepatic artery crossed the common hepatic artery in the proximal part of the hepatic pedicle, anterior to the portal vein. To our knowledge this type of anatomical variation has not been described before and it represents a rare finding that has to be kept in mind, especially in case of major hepatectomies and more demanding splitting liver procedures such as A.L.P.P.S., in situ split, ex situ split and living donor liver transplantation.

A new surgical technique for the management of shunting liver hemangiomas that otherwise would rapidly lead to intractable cardiac failure is presented. Rapid, significant reduction of shunt volume was achieved surgically by transhepatic compression sutures using PTFE pledgets and selective ligation of a large feeding vessel from the right hepatic artery.

False-negative findings on CT angiography (CTA) in two patients with hepatocellular carcinoma (HCC) were demonstrated. CTA images of one patient with an aberrant left hepatic artery branching from the left gastric artery and another patient whose right hepatic artery was occluded owing to an unknown cause failed to demonstrate HCCs. This report suggests one of the diagnostic pitfalls of CTA for diagnosis of liver tumors.

Vascular injuries following cholecystectomy are a known entity though the incidence is low. More frequently we are seeing cases of right hepatic artery pseudo aneurysm post cholecystectomy after the advent of the laparoscopic approach.We report a case of multiple right hepatic artery aneurysms as a complication of cholecystectomy in a 71-year-old patient.The diagnosis was confirmed by angiogram, and the patient was treated successfully with coil embolisation.Though it is a rare complication, early diagnosis and treatment of postoperative pseudo aneurysm is essential to prevent life threatening bleeding.

A 3-month-old infant with obvious hypertrophy affecting the right arm, leg, and face presented with a haemangioendothelioma arising from the right lobe of the liver that was not associated with cardiac failure. At diagnostic laparotomy the nature of the mass was confirmed and the right hepatic artery was ligated. Follow-up examination at 10 months revealed complete resolution of the intrahepatic mass. This appears to be the first report of an association between hemihypertrophy and hepatic haemangioendothelioma.

Anomalous arteries to the liver are not uncommon and usually arise from the superior mesenteric artery, the left gastric artery or directly from the aorta. We report a case of total replacement of the arteries to the right and left liver by separate right and left hepatic arteries arising from the gastroduodenal artery. The proper hepatic artery was absent. The gallbladder was supplied from the anomalous right hepatic artery.

Hemorrhage from portal and hepatic veins is a major concern with laparoscopic right hepatectomy (LRH). The standard hilar approach is dissection of the portal pedicle outside the liver parenchyma with separate transection of the right hepatic artery, portal vein, and bile duct. Variations in anatomy can hamper vascular and biliary control. The intrahepatic Glissonian access avoids these risks by en masse ligation of the portal structures without dissection for each separately. This technique was performed laparoscopically for the last 2 among 10 LRHs, and the results are presented.Total LRH was performed under ultrasound assistance for two patients with malignancy. After lymph node sampling at the hepatoduodenal ligament, dissection was started with the incision of liver parenchyma posterior and anterior to the hilum, then continued outside the portal pedicle bifurcation toward the right and left sheaths. An endoscopic vascular stapling device was placed to transect the right portal pedicle en masse under direct laparoscopic vision and cholangiography guidance. Parenchymal transection and vascular control of the right hepatic vein was accomplished with harmonic scalpel, cavitron ultrasonic aspirator, bipolar diathermy, clips, and endoscopic stapling device, as appropriate. No Pringle's maneuver was used. The specimen was extracted through a suprapubic incision using an endobag.The operative times for the two patients were, respectively, 180 and 240 min. No blood loss occurred during the intrahepatic Glissonian dissection. Intraoperative blood loss (from the right hepatic vein) of 700 and 800 ml, respectively, was controlled laparoscopically. The postoperative periods were uneventful, with discharge, respectively, on days 6 and 7. The surgical resection margins were free of tumor.The laparoscopic intrahepatic Glissonian approach used for right hepatectomy is safe, simple, and reproducible. It facilitates the hepatic hilar dissection with minimal operative risk. Further implementation of this technique is encouraged to improve the outcome for patients undergoing laparoscopic liver resection.

The right hepatic artery (RHA) may be the cause of a pseudocalculus in the common hepatic duct (CHD). Extrinsic pressure by the RHA on the CHD was seen in 15% of 61 retrograde cholangiograms and in 70% of 23 sonograms in which the RHA was identified. The anatomical relationship between the RHA and the CHD was confirmed by cast corrosion studies.

In contrast to conventional film angiography, the perfusion pattern of hepatic arterial chemotherapy was consistently visualized by DSA in 40 patients with implanted Infusaid pump or Port-A devices. Incomplete perfusion of a liver region by the cytotoxic agent was recognized by DSA as accurately as by nuclide scintigraphy. Furthermore, DSA appeared to be more sensitive in determining aberrantly perfused extrahepatic regions; this was especially true when there was a nonligated right hepatic artery. Specific details of vascular lesions and associated complicating events also could be satisfactorily analyzed by DSA only.

It has been accepted widely that filling defects in cholangiography are attributed to stones or tumors. However, we have recognized that filling defects at the hepatic hilum in cholangiography are caused by compression of the hepatic duct by the right hepatic artery. We studied 125 cases by cholangiography. Of these, 34 cases were subjected to simultaneous percutaneous transhepatic cholangiography and selective visceral arteriography. Among 125 cases, 25 cases (20%) showed filling defects at the hepatic hilum from compression by the right hepatic artery.