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Objective: Anatomic variations in the perigastric vessels during laparoscopic radical gastrectomy often affect the operator's judgment and prolong the operation time, and even cause accidental injury and surgical complications, and hence the safety and quality of the operation cannot be ensured. In this study, multiple slice CT was reconstructed by 3-dimensional CT simulation software (3D-CT), and 3D-CT images were used to describe the variation of celiac trunk and splenic artery before surgery. The guiding role of the different variation of vessels was analyzed for laparoscopic total gastrectomy+D2 lymph node dissection (LTG+D2LD). Methods: A retrospective cohort study was conducted. Case inclusion criteria: (1) Gastric cancer was at an advanced stage. All the patients were preoperatively examined by digestive endoscopy and 64-row enhanced CT scan, and were histopathologically diagnosed with gastric adenocarcinoma. (2) 3D-CT simulation images were reconstructed to guide the operation. (3) LTG+D2LD surgery was performed by the same surgical team. (4) Clinical data were complete, and all the patients had signed the informed consent. From 2014 to 2018, 98 patients with gastric cancer at the Gastrointestinal Surgery Department of Henan Provincial People's Hospital were enrolled. According to the Adachi classification, celiac trunk variation was divided into common type (Adachi type I) and rare type (Adachi type II-VI). According to the Natsume classification, splenic artery was classified into "flat type" and "curved type". Based on 3D-CT simulation images, variation of celiac trunk and splenic artery was described, and the differences in operation time, intraoperative blood loss and the number of postoperative retrieved lymph nodes were compared between groups with different types of arterial variation. Results: For celiac trunk, common type was found in 84 cases (86%) and rare type was found in 14 cases, including 6 cases (6%) of type II, 2 cases (2%) of type III, 2 cases (2%) of type IV, 3 cases (3%) of type V, 1 case (1%) of type VI. No other types were found. There were no statistically significant differences in clinical characteristics and number of retrieved lymph nodes between patients of the common type group and rare type group (all P >0.05). Compared with common type patients, those of rare type had longer operative time [(321.1±29.0) minutes vs. (295.1±46.5) minutes, t =2.081, P =0.040] and more intraoperative blood loss (median: 66.0 ml vs. 32.0 ml, Z =-4.974, P =0.001). For splenic artery, 41 patients (42%) were flat type and 57 patients (58%) were curved type. There were no statistically significant differences between the two groups in terms of clinical characteristics, intraoperative blood loss, operative time and number of retrieved lymph nodes (all P >0.05). Conclusions: The method of describing the variation in the perigastric vessels by 3D-CT simulation has certain clinical value in laparoscopic radical gastrectomy. The duration of LTG+D2LD is prolonged and the intraoperative blood loss is increased with the variation of celiac trunk, while the variation of splenic artery has no effect on LTG+D2LD.

Background: Accurate registration for surgical navigation of laparoscopic surgery is highly challenging due to vessel deformation. Here, we describe the design of a deformable model with improved matching accuracy by applying the finite element method (FEM). Material and methods: ANSYS software was used to simulate an FEM model of the vessel after pull-up based on laparoscopic gastrectomy requirements. The central line of the FEM model and the central line of the ground truth were drawn and compared. Based on the material and parameters determined from the animal experiment, a perigastric vessel FEM model of a gastric cancer patient was created, and its accuracy in a laparoscopic gastrectomy surgical scene was evaluated. Results: In the animal experiment, the FEM model created with Ogden foam material exhibited better results. The average distance between the two central lines was 6.5mm, and the average distance between their closest points was 3.8 mm. In the laparoscopic gastrectomy surgical scene, the FEM model and the true artery deformation demonstrated good coincidence. Conclusion: In this study, a deformable vessel model based on FEM was constructed using preoperative CT images to improve matching accuracy and to supply a reference for further research on deformation matching to facilitate laparoscopic gastrectomy navigation.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

Purpose: Our aim is to present a rare case of anatomic variation of the arterial blood supply to the liver because preoperative knowledge of hepatic vascular variations is mandatory in hepatic surgery and liver transplantation., Methods: We present a case of unusual arterial blood supply to the liver, a right hepatic artery coming from the splenic artery, associated to a classical common hepatic artery and a left hepatic artery from the left gastric artery. Preoperative diagnosis was made using CT-scan and 3D reconstruction., Results: The right hepatic artery was found behind the portal vein and its diameter showed its importance in the vascularisation of the liver. To our knowledge this type of variation has only twice been described before. The accuracy of the 3D reconstruction allowed us to adopt the best surgical strategy to avoid lesions of the two accessory arteries which proved important sources of blood supply., Conclusions: Precise preoperative evaluation of liver blood supply has great importance on surgical, transplantation strategy and outcome and rare anatomic variations have to be known to avoid lesions of potentially important arteries. New techniques of 3D reconstruction can ease the preoperative recognition of such difficult anatomic variations.