Article Commentary: Aberrant Hepatic Arterial Anatomy and the Whipple Procedure: Lessons Learned

Abstract

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.

Hepatic artery classification based on three-dimensional CT

“…For instance, most of the blood supply to the extrahepatic biliary tree comes from the RHA or rRHA. Accidental injury to these arteries during hepatic surgery might lead to ischaemia of the biliary anastomosis. Ishigami and colleagues reported that variant hepatic artery anatomy in a liver transplant recipient increased the risk of hepatic artery complications after transplantation by 18 per cent.…”

Robotic pancreaticoduodenectomy in the presence of aberrant or anomalous hepatic arterial anatomy: safety and oncologic outcomes

“…The presence of an aberrant RHA has been shown in many studies not to impact outcomes in open PD . Descriptions of the impacts of other less common arterial anomalies on PD are mostly limited to review articles and small case series or reports . This is the first study to examine the impact of HAAs on the outcomes of minimally invasive PD.…”

Aberrant Right Hepatic Artery with a Prepancreatic Course Visualized Prior to Pancreaticoduodenectomy

“…6 Of note, angiography has been replaced by angio-MRI or angio-CT to assess vascularization. 7 In particular, angio-CT is accurate LGA left gastric artery, a LHA aberrant left hepatic artery, P pancreas, a RHA aberrant right hepatic artery, VP portal vein, VC vena cava, SMA superior mesenteric artery to predict resectability of pancreas head tumors in 80 % of cases. 8 The other interesting feature of this case is the prepancreatic course of the aRHA, instead of the classically described retropancreatic and latero-cave course.…”

“…9 There is however a risk of long-term biliary ischemia, or even necrosis of a hepatic segment, or a risk of bile leak on the biliojejunostomy if the vascular supply is due to the aRHA. 7 On the other hand, this risk is still debated. 7 Others propose the reimplantation of the aRHA on the gastroduodenal artery to limit the ischemic risk, but this technique has been claimed to increase the risk of lethal hemorrhage in case of postoperative pancreatic fistula.…”

“…7 On the other hand, this risk is still debated. 7 Others propose the reimplantation of the aRHA on the gastroduodenal artery to limit the ischemic risk, but this technique has been claimed to increase the risk of lethal hemorrhage in case of postoperative pancreatic fistula. 9…”