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Purpose: 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., Method: A 54-year-old female with oligometastatic colorectal cancer with metastases to the liver presented for planning stage arteriography in preparation for Y90 radioembolization., Results: 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., Conclusion: 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., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objective: The aim of this study was to evaluate the utility of the Pulsatility Index (PI) of the right hepatic artery, measured by color Doppler sonography, in the diagnosis of acute cholecystitis., Methods: Seventy-five subjects were included in this study and divided into three groups, each consisting of 25 subjects: the cholecystitis group, the asymptomatic cholelithiasis group, and normal controls. Patients with acute cholecystitis fulfilled all the diagnostic criteria as stated in the latest Tokyo Guidelines. In all patients, the right hepatic artery was detected by color Doppler ultrasound and the PI was measured., Results: Patients with acute cholecystitis were found to have significantly higher PI values compared to both normal controls and cholelithiasis patients. Regression analysis revealed a significant positive correlation between the PI and the cholecystitis outcome., Conclusion: Measurement of PI by color Doppler ultrasound represents a useful aid in the diagnostic process of acute cholecystitis. More studies are needed before this method is incorporated in the relevant guidelines., (Copyright © 2020 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

Introduction: Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality., Methodology: The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed., Results: Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series., Conclusion: Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation., (Copyright © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Introduction: The aim of this study was to evaluate the effect of hepatic artery (HA) size mismatch anastomosis on outcomes after living-donor liver transplantation (LDLT)., Materials and Methods: After excluding 128 patients with the exclusion criteria among 233 LDLTs using the right lobe, 104 LDLT patients were divided into two groups: donor HA diameter that was greater than or equal to the recipient HA diameter (D ≥ R group; n = 79), and donor HA diameter that was smaller than the recipient HA diameter (D < R group; n = 25)., Results: Hepatic artery-related complications occurred in only one patient (HA thrombosis; 1.0%) who was in the D < R group. The reconstructed HA flow in the D ≥ R group was significantly greater than that in the D < R group (P = 0.015). There was a higher incidence of anastomotic biliary stricture in the D < R group (32.0%) compared with the D ≥ R group (13.9%, P = 0.022) after LDLT. A multivariate analysis with Cox regression revealed that the HA anastomosis of the D < R group and hepaticojejunostomy were significant independent risk factors for postoperative anastomotic biliary stenosis., Conclusions: Hepatic artery anastomosis with a donor HA diameter smaller than that of the recipient HA might be an independent risk factor for postoperative biliary stenosis after LDLT using the right lobe., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Right hepatic artery (RHA) injury is a complication that occurs during laparoscopic cholecystectomy, which can sometimes cause hepatic artery pseudoaneurysm or ischemic hepatic necrosis. Therefore, RHA should be managed carefully. Herein, we report a case of intraoperative RHA injury that was successfully repaired during laparoscopic cholecystectomy. Bleeding was controlled prior to the cholecystectomy with vascular clamp forceps that had been inserted through an additional trocar, and repair of the RHA injury was then performed laparoscopically. The postoperative course was uneventful, and patency of the RHA and its sectional arteries were confirmed by CT arteriography. Laparoscopic repair of minor RHA injuries can be managed safely if bleeding is adequately controlled., (© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Objective and Background: Despite its importance in pancreatic head carcinoma, the retroportal lamina is still under studied, with only two anatomical cadaveric dissections in the English literature, with recent controversies about the concept of a mesopancreas., Methods: Resection of the mesopancreas was performed in 33 fresh cadavers. The pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated., Results: The retroportal lamina is roughly rectangular in shape. Its dimensions are: height 6.2 cm (5-8), 2.5 cm wide (1.5-4). It contains a right hepatic artery arising from the superior mesenteric artery in 13.3% of cases. Microscopic examination revealed areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatics and capillaries. However, fibrous sheath and fascia were not found around these structures., Conclusion: A right hepatic artery arising from the superior mesenteric artery is a frequent anatomic variation. Surgeons must be aware of this to ensure the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Despite controversy about the reality of the mesopancreas (postulated in analogy to the mesorectum), because of the absence of fibrous sheath or fascia, its complete removal in pancreatic head carcinoma is feasible by a subadventitial dissection of the superior mesenteric artery which can be considered as the real limit of the mesopancreas., (Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Cholelithiasis is the most common disease worldwide, and laparoscopic cholecystectomy is the standard treatment of choice. To perform laparoscopic cholecystectomy, it is essential to understand the critical view of safety, which primarily involves the dissection of Calot's triangle. Anatomical variations in Calot's triangle exist, and understanding them is crucial to avoid unintended situations during surgery. Mirizzi syndrome, a rare complication in Calot's triangle, can significantly increase mortality and morbidity rates. Aim: To evaluate the anatomical variations in the Calot's triangle. Materials and Methods: A cross-sectional study was conducted at Mayo Institute of Medical Sciences, Department of General Surgery, from October 2021 to September 2022. The total sample size included 100 patients with gallstone disease who underwent surgical intervention. Intraoperative findings, such as variations in the cystic artery and cystic duct, as well as Mirizzi syndrome grading, were recorded in an Excel sheet and tabulated. The results were expressed in terms of frequency and percentage. Results: The average age of the patients was 39.42±12.11 years, with females outnumbering males. Among them, 28% had a cystic artery lying outside of Calot's triangle, and 96% had a cystic artery originating from the right hepatic artery. The remaining 2% originated from an aberrant right hepatic artery, 1% from the left hepatic artery, and 1% from the gastroduodenal artery. Cystic duct variations were found in 5% of cases. Of these, 2% had a short cystic duct (<2 cm), 1% had a long cystic duct (approximately 5 cm), one patient had an absent cystic duct, and one had a low insertion into the common hepatic duct. Mirizzi syndrome Grade-I and Grade-II patients accounted for 4% and 2% respectively, while Grade-III, Grade-IV, and Grade-V each contributed to 1%. Conclusion: Knowledge of Calot's triangle variations is crucial, especially for aspiring surgeons, as it helps them make decisions promptly when encountering difficulties during surgery. Understanding the Calot's region ensures the safety not only of patients but also of surgeons. [ABSTRACT FROM AUTHOR]

Background: An aberrant vascular anatomy might present a technical pitfall for biliary atresia (BA) surgery. The purpose of this study was to report the rare cases and discuss the significance and management strategy for BA with an aberrant right hepatic artery (ARHA) by laparoscopic Kasai procedure in children. Methods: The subjects for this study were 10 consecutive type III BA patients with an ARHA who had laparoscopic Kasai procedure at our institute between January 2012 and August 2021. The common bile duct was mobilized between the right hepatic artery and the right branch of portal vein, and then lifted to the liver hilum. The fibrous cord was transected and then the laparoscopic Kasai was carried out. Results: All patients survived the laparoscopic Kasai without any intraoperative complications. The mean operative time was 235 minutes for each laparoscopic Kasai. The mean follow-up time was 32.6 months. The total and direct bilirubin dropped to normal within 4 months of surgery in 7 patients. One patient died of repeated cholangitis and liver failure 1 year after surgery. In the additional 2 patients the bilirubin levels dropped significantly after the surgery but elevated again because of repeated cholangitis and requiring ongoing observation and intermittent treatment. Conclusions: With the perfect laparoscopic skills, the common bile duct could be safely mobilized between the right hepatic artery and right branch of portal vein for the infants with type III BA associated with an ARHA, and laparoscopic Kasai could be carried out safely and successfully. [ABSTRACT FROM AUTHOR]

Modern medicine is developing towards application of endovascular techniques such as trans-arterial hepatic chemoembolisation. They displace classic open procedures. However, their correct planning and performance depend on the knowledge pre-operative detection of hepatic arterial anatomical variations. The main abnormality that may generate complications during radiological and surgical procedures is occurrence of an accessory hepatic artery. In the present study we propose our own classification of the variability observed in the vessels based on cases reported in the literature. It analyses more types of variations as compared to previous trials. A great advantage of this study is also a description of different pathological and frequently life-threatening conditions associated with hepatic arteries. This study is of value to medical practitioners, e.g. surgeons. [ABSTRACT FROM AUTHOR]

Purpose: It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD. Methods: All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015. Results: There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group. Conclusion: We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic Cholecystectomy is widely accepted as the gold standard in the treatment of cholelithiasis and this new technique was initially associated with a significant increase in morbidity, and in particular, in iatrogenic biliary injury and arterial haemorrhage, perhaps due to a lack of knowledge of the laparoscopic anatomy of the gallbladder pedicle.The arterial system of human body is often subjected to a good number of variations. Therefore, trying to find out variations in origin of right and left hepatic arteries and also cystic artery will surely be a useful endeavor for an Anatomist and Autopsy Surgeon, moreover such an effort will help the surgeons in planning and operating upon the hepatobiliary system. Method:The present work was carried out in the Department of FMT, NRSMCH, Kolkata in collaboration with the Department of Anatomy, Medical College, Kolkata over a period of one year to find out variations ion origin of right and left hepatic arteries and cystic artery. Fifty cadavers of both sexes were subjected to detail dissection method based on inclusion and exclusion criteria. The study was prospective, cross sectional, observational, autopsy based study. Conclusion:In 92% cases total number of branches from the HAP were three, four branches were arising from it in 6% cases, whereas >four branches from the HAP in remaining 2% cases.The branching pattern of the HAP at the porta hepatis showed bifurcation in 96 % cases, whereas HAP showed trifurcation pattern at porta hepatis in 4% cases.Any source of origin of the RHA and LHA other than the HAP was recorded as 0%. The percentage of occurrence of accessory or replaced RHA was 0%.This was also the case with LHA. The present study revealed the RHA (92%) being the commonest source of origin of cystic artery. In 8% cases cystic artery represented variant origin. Variant origins of CA were represented by the HAP (6%) and GDA (2%). In 96% of cases, the cystic artery was single. Remaining 4% of cadavers showed presence of more than one cystic artery, the number being two. Most significant finding in this present study according to the researcher is the presence of double cystic arteries. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy is the treatment indicated for cholelithiasis, however the procedure is not free of complications or concomitant morbidity. It is possible that, due to collateral ductal lesions, bleeding occurs with the possibility of surgery conversion and undesirable results. For a correct approach to the region it is essential to identify the cystohepatic trigone (CHT) and its components, as well as the ligation and section of the cystic artery (AC). Knowing the high variability of CA, the aim of this work was to identify the number, origin, path and relationship of CA with the CHT and its variations using angiotomography by means of a 64-slice detector tomograph in the preoperative period of 30 female patients, between 24 and 54 years old, with clinically diagnosed cholelithiasis and by echo sonography. The AC in 76.67% was unique and was within the CHT, in 16.67% it was unique and was observed outside the CHT. In 6.67%, two ACs were observed, one inside and one outside the TCH. In 66.67% of cases, CA originated normally from the right hepatic artery. The traceability of AC was 53.3% moderately visible and 46.7% excellent traceability. In conclusion, the identification of AC and its anatomical variations can be determined in the preoperative period and can be useful to improve the surgical plan in patients with cholelithiasis, providing information on the procedure, optimizing it and reducing the risks of possible bleeding related complications. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy has been started to be applied in the field of surgery in the 1990s and became the gold standard in treatment in a short time period. The generally applied method in laparoscopic cholecystectomy is the infundibular technique and calot dissection is of great importance for a safe cholecystectomy. In this presentation, we presented a rare hepatic artery variation that we noticed after calot dissection during laparoscopic cholecystectomy in the light of the literature. [ABSTRACT FROM AUTHOR]

Background: Lower gastrointestinal (GI) bleeding is predominantly caused by hemorrhoids, angiodysplasias, diverticular disease, inflammatory bowel disease, or polyps. However, on rare occasions, it occurs from another etiology. Right hepatic artery (RHA) pseudoaneurysm is a rare entity, attributed to infections, trauma, and upper abdominal surgery. Most cases occur after biliary and pancreatic surgery. We present a case of a 60-year-old male with lower GI bleeding caused by RHA pseudoaneurysm tear. Case Report: The patient with a history of chronic alcoholic pancreatitis and obstructive icterus was admitted to the hospital in March 2020 on account of experiencing syncope and the presence of bright red blood in his stool. His biliary obstruction was primarily treated by ERCP in 2019 but due to the persistence of symptoms he had undergone biliary surgery (cholecystectomy and choledochojejunostomy) in January 2020. Physical examination revealed signs of hemodynamic instability and lab results showed signs of anemia. Esophagogastroduodenoscopy (EGD) was done to exclude upper GI bleeding and it was followed by a colonoscopy which showed fresh blood in the colon and terminal ileum. Computed tomography (CT) angiography showed no abnormalities. The patient was hospitalized and put on symptomatic therapy. In the following days, his BP dropped and he developed tachycardia as a sign of recurrent bleeding. EGD and colonoscopy were performed again and showed the same findings. Digital subtraction angiography (DSA) of abdominal arteries subsequently showed a pseudoaneurysm of the right hepatic artery, which was immediately treated by “sandwich” coil embolization. After the procedure, the patient became stable and was discharged from the hospital without experiencing a relapse of gastrointestinal bleeding. Conclusion: RHA pseudoaneurysm is a serious potential complication of abdominal surgery. Early recognition and emergency management of RHA pseudoaneurysm are crucial for a favorable patient outcome. [ABSTRACT FROM AUTHOR]

Anatomical variations of the hepatic arteries are not uncommon. The anomalous hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic or liver transplantation and in laparoscopic surgery. We describe an unusual case of a 66-year-old Greek male cadaver, where a rare anastomosis (in the form of an enlarged arterial loop, 4.84 mm in diameter) between the common hepatic artery (6.42 mm) and the gastroduodenal artery (GDA) (4.82 mm) coexisted with an aberrant right hepatic artery (ARHA) (6.38 mm) originating from the superior mesenteric artery. The proper hepatic artery was absent. The ARHA followed a route posterior to the portal vein and the common hepatic duct, entering the liver and supplying the right hepatic segment. A hypoplastic right gastric artery emanated from the GDA. Our case report highlights the combined variations of hepatic arteries and possible anastomoses emphasizing that a thorough knowledge of the classic and variable hepatic arterial anatomy are mandatory for surgeons and radiologists performing hepatic surgery and arteriography to avoid potential iatrogenic injuries in hepatobiliary and pancreas area and further medico-legal implications. [ABSTRACT FROM AUTHOR]

The presence of arterial variants in patients scheduled for pancreatico-duodenectomy is not uncommon and should be preoperatively detected because it may influence the intraoperative strategy. Ligation of the gastro-duodenal artery is a critical step during pancreaticoduodenectomies. However, the impact of anatomical variants of gastro-duodenal artery was poorly investigated. Hereby, it is presented the case of a patient who underwent pancreaticoduodenectomy for distal bile duct cholangiocarcinoma and with anatomical variant of origin for gastro-duodenal artery from right hepatic artery. Proper recognition of arterial anatomy during pancreatico-duodenectomies is of utmost importance to avoid postoperative complications. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Here we present a unique case of variation in the branching pattern of the coeliac trunk. In the present case, the coeliac trunk was replaced by two separate arterial trunks. The first arterial trunk bifurcated into the left gastric and the left hepatic arteries. The second arterial trunk bifurcated into a splenic artery and a hepato-gastroduodenal trunk. The hepato-gastroduodenal trunk presented an unusual course and termination. The right hepatic artery arising from the hepato-gastroduodenal trunk also showed a variant course. Such rare variations are important for gastroenterological surgeons and interventional radiologists due to increase in number of transplantation surgeries and live donor liver transplantations. [ABSTRACT FROM AUTHOR]

Lymph node metastasis from gallbladder cancer is often found in the pericholedochal area; however, these regional lymph nodes are not typically accompanied by arteries. We hypothesized that the artery accompanying pericholedochal lymph nodes was either the regressed embryonic right hepatic artery (eRHA) or an aberrant right hepatic artery (aRHA) remaining without regression. This study aimed to determine the artery supplying pericholedochal lymph nodes. We obtained serial tissue sections of resected specimens from 10 patients who underwent pancreaticoduodenectomy with combined resection of the superior mesenteric artery and vein and investigated the association between the distribution of enlarged lymph nodes and the course of blood vessels in each section. In 2 cases with aRHA, enlarged lymph nodes were distributed in the posterosuperior area, pancreaticoduodenal region and retroportal area along this artery. By contrast, no blood vessels accompanied enlarged lymph nodes in 8 patients exhibiting a normal hepatic artery branching pattern, although these nodes exhibited a distribution pattern similar to that of patients with the aRHA. Thus, the artery supplying pericholedochal lymph nodes appears to be either the regressed eRHA or an aRHA persisting without regression. [ABSTRACT FROM AUTHOR]