A morphological study of the inferior phrenic arteries on multidetector computed tomography and angiography.

INTRODUCTION: The inferior phrenic artery is a paired artery with a variable origin and course, primarily supplying the diaphragm, but also the suprarenal glands, inferior vena cava, stomach, and oesophagus. The aim of this study is to investigate the origin and course of the inferior phrenic arteries on multidetector computed tomography and angiography. MATERIALS AND METHODS: The anatomy of the inferior phrenic artery was analysed on 2449 multidetector computed tomography scans. Three-dimensional reconstructions were made of the main variations. Additionally, the course and branching pattern of the inferior phrenic artery were descriptively analysed in a cohort of 28 angiograms. RESULTS: In 565 (23.1%) cases the inferior phrenic arteries arose as a common trunk and in 1884 (76.9%) cases as individual vessels. The most common origins of a common trunk were the coeliac trunk (n=303; 53.6%) and abdominal aorta (n=255; 45.1%). The most common origins of the right inferior phrenic artery were the coeliac trunk (n=965; 51.2%), abdominal aorta (n=562; 29.8%) and renal arteries (n=214; 11.4%). The most common origins of the left inferior phrenic artery were the coeliac trunk (n=1293; 68.6%) and abdominal aorta (n=403; 21.4%). CONCLUSION: The inferior phrenic artery has a very variable anatomy. The most common origins of the inferior phrenic artery are the coeliac trunk and its branches, the abdominal aorta, and the renal arteries.

Comprehensive analysis of splenic artery variations using computed tomography angiography: development of the IPALGEA classification system.

BACKGROUND: The splenic artery, an essential component of abdominal vascular anatomy, exhibits significant variations with clinical implications in surgical and radiological procedures. The lack of a standardized classification system for these variations hinders comparative studies and surgical planning. This study introduces the IPALGEA classification system, based on computed tomography angiography (CTA) findings, to address this gap. METHODS: A retrospective analysis was conducted on 302 patients who underwent CTA at a tertiary university hospital between August 2021 and January 2022. The study focused on the evaluation of splenic artery variations, including the origin, course, terminal branching patterns, and the relationship between the inferior polar artery and the left gastroepiploic artery. The IPALGEA classification was developed to standardize the reporting of these variations. RESULTS: The study highlighted a significant prevalence of splenic artery variations, with the most common pattern being a superior course relative to the pancreas. The IPALGEA classification effectively categorized these variations, emphasizing the relationship between the inferior polar artery and the left gastroepiploic artery. The findings revealed that the bifurcation distance of the celiac trunk varied significantly between genders and that the presence of an inferior polar artery correlated with a shorter hilus distance. CONCLUSION: The IPALGEA classification offers a comprehensive and standardized approach to categorize splenic artery variations. This system enhances our understanding of abdominal vascular anatomy and has significant implications for surgical and radiological procedures, potentially reducing surgical complications and improving patient outcomes.

Anatomical Variations in the Celiac Trunk: A Short Review.

OBJECTIVE: The objective of the current study was the examination of possible variants of the celiac trunk. METHODS: An advanced review of the literature search was undertaken by means of the PubMed database and Google Scholar, searching for new studies published up to October 2022. Additional articles provided useful information in relation to the aim of this review. Hence, articles that met the inclusion criteria were included in this review and the collected data were organized into a table. RESULTS: The search of the literature retrieved 10 articles that referred to the anatomical variations of the celiac trunk. According to the available literature, the most common anatomical variations are: hepatosplenic trunk where the left gastric artery originates from the abdominal aorta, hepatosplenic trunk, where the left gastric artery originates from the splenic artery, and hepatogastric trunk and splenic artery origin from the superior mesenteric artery. Many other anatomical variations of the celiac trunk may exist, such as tetrafurcation, pentafurcation and hexafurcation, that refer to the division of the celiac trunk into four, five or six branches, respectively, and should be reported as they can affect surgical approaches and the development of the appropriate treatment strategy in patients. CONCLUSION: Every visceral surgeon, interventional radiologist and abdominal imager should be familiar with these variants.

Anatomical Variations in the Branching Pattern of the Celiac Trunk, Number of Originating Arteries and Position of the Kidneys: A Cadaveric Dissection Report.

According to anatomical reference books, the celiac trunk (CT) is divided into three terminal branches, namely the common hepatic artery (CHA), left gastric artery (LGA), and splenic artery (SA). However, variations in the number and location of the CT branches are possible. The body of a 40-year-old deceased male was used for anatomization in the Anatomical Hall of Alborz University of Medical Sciences (Karaj, Iran). During the dissection, variations in the branching pattern of the CT, such as the orientation of the main celiac branches, the origin of the inferior phrenic artery, and the aberrant supplementary artery to supply the liver were observed. Furthermore, a variation in the location of the kidneys and renal arteries was observed. In addition to CHA, LGA, and SA, two additional branching patterns, namely the left inferior phrenic artery (LIPA), and right accessory hepatic artery (RAHA) were noticed. This variation is rarely observed in human anatomy. Therefore, awareness of the arterial anatomy and possible variations is essential during surgeries (e.g., biliary tract surgery, liver transplant) and radiological procedures. To the best of our knowledge, such variations in the branching pattern of the CT have not been reported or described in anatomical reference books. Hence, the present study aimed to highlight the existence of these variations to assist surgeons, radiologists, and anatomists.

Evaluation of celiac artery and common hepatic artery variations by CT-angiography and new classification model.

PURPOSE: Knowledge of anatomical variations is important in all interventional procedures. This study aims to evaluate the variations and prevalence of celiac trunk (CeT) and its branches. METHODS: The computerized tomography-angiography (CT-A) findings of 941 adult patients were evaluated retrospectively. Variations of the CeT and common hepatic artery (CHA) were evaluated according to the number of branches and their origin. Findings were compared with classical classification methods. A new classification model has been defined. RESULTS: Normal (complete) trifurcation was detected in 856 (90.9%) of them, where left gastric artery (LGA), splenic artery (SpA) and CHA branches were derived from the CeT. Among 856 complete trifurcation cases, 773 (90.3%) had non-classical trifurcation patterns. The rate of classic trifurcation was 8.8%, while non-classic trifurcation was 82.1% in all cases. In one case (0.1%), LGA and left hepatic artery together and right hepatic artery and SpA together appeared as a double bifurcation. Complete celiacomesenteric trunk was observed only in 4 (0.42%) cases. In seven cases (0.7%), LGA, SpA and CHA were coming out of abdominal aorta (AAo) independently. CHA normal anatomy (Michels Type I) was detected in 618 (65.5%) patients. We found that 49 (5.2%) of our cases were ambiguous according to the Michels Classification. We have described five different variations of hepatic arteries directly arising from the AAo. CONCLUSION: Preoperative recognition of anatomical variations of CeT, superior mesenteric artery and CHA is of primary importance in both surgical and radiological procedures. With careful evaluation of CT-angiographies, it is possible to detect rare variations.

Absent celiac trunk and unusual arterial anatomy of the upper abdomen: into the deep.

The celiac trunk is the first major branch of the abdominal aorta. It originates from the ventral aspect of the aorta at the level of T12-L1 vertebrae and was originally described as an artery that branches into the common hepatic artery, left gastric artery, and splenic artery. Absence of the celiac trunk and origin of the three arteries separately from the aorta is a rare entity that is reported in 0.38% to 2.6% of cases. It is even more uncommon that this variation can be accompanied by other vascular variations of the upper abdomen as accessory arteries to the liver, stomach, and pancreas. These cases arise during embryogenesis due to decreased arterial degeneration combined with decreased arterial fusion, which results in the anatomical variations present in the current case. Complex arterial variations are both a risk for iatrogenic injury during surgical procedures and beneficial during endovascular supply as they may provide additional access for embolization and chemotherapy.

Anatomy of the splenic artery: what does the surgeon need to know?

OBJECTIVE: to determine the prevalence and describe the main morphological and metric variations of the splenic artery in terms of its origin, path and polar and terminal branches. METHODS: cross-sectional study, carried out at Hospital de Clínicas between July and November 2020. Computed tomography scans were analyzed with intravenous contrast of the patients seen at the Radiology and Diagnostic Imaging Service. The findings were categorized as to origin, path and splenic ramifications. RESULTS: 1,235 patients were evaluated. As for the origin, the splenic artery appears in the celiac trunk in 99.11% of the individuals. Of these, 5.95% have a bifurcated celiac pattern, 92.17% trifurcated and 1.88% tetrafurcated. The mean arterial diameter was 5.92mm (±1.2), the highest one being in white men. As for the path, the splenic artery was unique in the entire sample. The suprapancreatic course was found in 75.63% of the individuals, with a higher occurrence in women, 78.87% (p<0.001). The terminal splitting pattern of the splenic artery was characterized by the bifurcated type (95.47%). The terminal branches seen most frequently were those with three arteries (34.90%) and most individuals did not have polar branches. CONCLUSION: the splenic artery presents a highly variable pattern of origin and its average caliber is influenced by sex and color. The suprapancreatic path was the most characteristic and predominant in females. The bifurcated pattern of final division, with three terminal branches and the absence of polar arteries, occurs more frequently.

Evaluación anatómica del tronco celíaco y sus ramas en una muestra de población mestiza colombiana / Anatomical evaluation of the celiac trunk and its branches in a sample of Colombian mestizo population

RESUMEN: El tronco celíaco (TC) es la rama de la arteria aorta abdominal (AA) que aporta la irrigación a la porción distal del esófago, parte media del duodeno, al estómago, páncreas, bazo y suple adicionalmente al hígado; sus diferentes expresiones anatómicas son reportadas en los diferentes grupos poblacionales con incidencia variable. Se evaluó las características morfológicas del TC y sus ramas en 26 bloques del piso supramesocólico de cadáveres masculinos adultos no reclamados, del grupo poblacional mestizo, a quienes se les practico autopsia en el Instituto de Medicina Legal de Bucaramanga - Colombia. Se observo el tipo I del TC en 23 especímenes (88,4 %), del cual correspondió 16 muestras (61,5 %). Al subtipo Ia con bifurcación y formación de tronco hepatoesplénico. Hubo un caso (3,8 %) en donde las ramas del T se originaron de manera independiente de la AA. El TC presentó una longitud promedio de 18,6 DE 7,53 mm y un diámetro externo de 7 DE 1,24 mm. De las ramas del TC, la AE presentó un diámetro promedio de 5,89 DE 1,04 mm sin diferencias estadísticamente significativa con relación al diámetro de la AHC, pero si con relación al diámetro de la AGI (P= 0,70; p<0,001 respectivamente). La gran mayoría de la muestra avaluada muestra la presencia de tronco hepatoesplénico seguido de la trifurcación en una verdadera configuración de trípode. El conocimiento de los patrones de ramificación del TC debe ser tomado en cuenta por cirujanos gastroenterólogos, radiólogos intervencionistas y oncólogos para evitar complicaciones durante los procedimientos quirúrgicos abdominales.

SUMMARY: The celiac trunk (CT) is the branch of the abdominal aorta artery (AA) that provides irrigation to the distal portion of the esophagus, the middle part of the duodenum, the stomach, pancreas, spleen and additionally supplies the liver; its different anatomical expressions are reported in the different population groups with variable incidence. The morphological characteristics of the CT and its branches were evaluated in 26 blocks of the supramesocolic floor of unclaimed adult male corpses, of the mestizo population group, who were autopsied at the Institute of Legal Medicine of Bucaramanga - Colombia. Type I CT was observed in 23 specimens (88.4 %), of which 16 samples (61.5 %) corresponded. to subtype Ia with bifurcation and formation of the hepatosplenic trunk. There was one case (3.8 %) in which the branches of the CT originated independently of the AA. The CT had an average length of 18.6 SD 7.53 mm and an external diameter of 7 SD 1.24 mm. Of the CT branches, the splenic artery presented an average diameter of 5.89 SD 1.04 mm without statistically significant differences in relation to the diameter of the AHC, but if in relation to the diameter of the IGA (P = 0.70; p <0.001 respectively). The vast majority of the sample evaluated shows the presence of a hepatosplenic trunk followed by trifurcation in a true tripod configuration. Knowledge of CT branching patterns should be taken into account by gastroenterological surgeons, interventional radiologists, and oncologists to avoid complications during abdominal surgical procedures.

A comprehensive study of right and left inferior phrenic artery variations in 1000 patients with multidetector computed tomography angiography: an important study for HCC.

PURPOSE: To investigate the anatomic variations in the origins of the right and left inferior phrenic arteries (IPAs) using multidetector computed tomography and to classify their combined variations. METHODS: This retrospective study included patients undergoing abdominal aorta angiography between January 2015 and October 2019. The RIPA and LIPA origins were evaluated both separately and combined on three-dimensional images. The variant patterns of the IPAs were determined and classified. The numerical evaluation of the data was performed with SPSS 21. RESULTS: In total, 1000 patients (478 women, 522 men) were evaluated. The IPAs originated from a common trunk or a common root in 360 (36.00%) patients, while the IPAs originated independently without a common trunk in 609 (60.90%) patients. The most common combined variant detected in the present study was IPAs originating as a common trunk from the coeliac trunk in 197 (19.70%) patients; 14 (1.40%) patients had no inferior phrenic artery (IPA), and 17 (1.70%) patients had only one IPA. CONCLUSION: Fifty-two different types of variations in the combined origin of the inferior phrenic arteries were described in this study for the first time in the literature. Awareness of the anatomic variations in the IPAs, which is critical for hepatocellular carcinoma origins, may benefit various clinical procedures, such as transcatheter arterial chemoembolization, organ transplantations, laparoscopic surgical procedures, and radiological procedures.

Perceptions of porta-celiac vascular models for hepatic surgery and their use in residency training.

BACKGROUND: Primary aspect of hepatic navigation surgery is the identification of source vascular details to preserve healthy liver which has a vascular anatomy quite challenging for the young surgeons. The purpose was to determine whether three-dimensional (3D) vascular pattern models of preoperative computed tomography (CT) images will assist resident-level trainees for hepatic surgery. METHODS: This study was based on the perception of residents who were presented with 5 different hepatic source vascular patterns and required to compare their perception level of CT, and 1:1 models in terms of importance of variability, differential of patterns and preoperative planning. RESULTS: All residents agree that models provided better understanding of vascular source and improved preplanning. Five stations provided qualitative assessment with results showing the usefulness of porta-celiac models when used as anatomical tools in preplanning (p = 0.04), simulation of interventional procedures (p = 0.02), surgical education (p = 0.01). None of the cases had scored less than 8.5. Responses related to understanding variations were significantly higher in the perception of the 3D model in all cases, furthermore 3D models were more useful for seniors in more complex cases 3 and 5. Some open-ended answers: "The 3D model can completely change the operation plan" One of the major factors for anatomical resection of liver transplantation is the positional relationship between the hepatic arteries and the portal veins. CONCLUSION: The plastic-like material presenting the hepatic vascularity enables the visualization of the origin, pattern, shape, and angle of the branches with appropriate spatial perception thus making it well-structured.

Morphological speculation of the MHPD and related clinical projections.

OBJECTIVE: The concept of mesopancreas has been brought into focus nowadays. Studies on membrane morphology of pancreas are clinically significant in determining an ideal surgical route for a "holy plane". In this paper, we aimed to observe the structure of the peripancreatic membranes and its interactions with adjacent tissues; tentatively put forward the proposition of mesohepatopancreaticoduodenum (MHPD) and explore in depth in surgical local resection. METHODS: 33 cadavers were examined in the experiment, including 30 for gross anatomy and 3 for histological observation after transection. The histological characteristics of the membrane covering the pancreas were proved by Masson and Bielschowsky silver staining and further explored in clinical application and testified in a surgical scenario. All above were carried out through traditional procedures. RESULTS: The anterior surface membrane of the pancreas was intact and the posterior portion expanding to the pancreaticoduodenum enclosed the surface of the duodenum and the pancreatic head, which could be easily isolated from the posterior abdominal wall. The posterior surface membrane around the body and tail wrapped the pancreatic parenchyma, which created a soft-tissue window for the posterior abdominal wall. Then, dense connective tissue adhesions were detected between the celiac artery and the superior mesenteric artery. CONCLUSIONS: The embryonic origin of the mesopancreas and the surgical procedures were reviewed and inspected based on the proposition of MHPD and above results. We hope that this study could stir up our interest in the advancement of imaging diagnoses and minimally invasive surgical treatment of pancreas.

What comprises the plate-like structure between the pancreatic head and the celiac trunk and superior mesenteric artery? A proposal for the term "P-A ligament" based on anatomical findings.

A plate-like structure is located posterior to the portal vein system, between the pancreatic head and roots and/or branches of two major arteries of the aorta: the celiac trunk and superior mesenteric artery. We aimed to clarify the distribution and components of this plate-like structure. Macroscopic examination of the upper abdomen and histological examination of the plate-like structure were performed on 26 cadavers. The plate-like structure is connected to major arteries (aorta, celiac trunk, superior mesenteric artery) and the pancreatic head; it contains abundant fibrous bundles comprising nerves, vessels, collagen fibers, and adipose tissue. Furthermore, it consists of three partly overlapping fibrous components: rich fibrous bundles (superior mesenteric artery plexus) fused to the uncinate process of the pancreas; fibrous bundles arising from the right celiac ganglion and celiac trunk that spread radially to the dorsal side of the pancreatic head and superior mesenteric artery plexus; and fibrous bundles, accompanied by the inferior pancreaticoduodenal artery, entering the pancreatic head. The plate-like structure is the pancreas-major arteries (aorta, celiac trunk, superior mesenteric artery) ligament (P-A ligament). The term "P-A ligament" may be clinically useful and can facilitate comprehensive understanding of the anatomy surrounding the pancreatic head and provide an anatomical basis for further pancreatic surgery studies.

Distance measurements and origin levels of the coeliac trunk, superior mesenteric artery, and inferior mesenteric artery by multiple-detector computed tomography angiography.

The aim of this study is to determine vertebral levels of the coeliac trunk, the superior mesenteric artery, and the inferior mesenteric artery originated from the abdominal aorta and to calculate the distance measurements between these arteries and between these arteries and the aortic bifurcation by multidetector computed tomography angiography technique. It was determined that the nine different vertebral levels of the coeliac trunk, the nine different vertebral levels of the superior mesenteric artery, and the eleven different vertebral levels of the inferior mesenteric artery. The distance measurements between the coeliac trunk and the superior mesenteric artery, the inferior mesenteric artery, the aortic bifurcation were found significant between female and male. In this study, it was determined more different levels than the levels described in classical anatomy. The preoperative information of these morphological variations can contribute to the reduction of surgical time and perioperative vascular complications especially for anterior lumbar interbody fusion and defining the location of the primary lymphatic drainage site for gastrointestinal malignancies.

Unusual variations in the branching pattern of the coeliac trunk and their clinical significance.

BACKGROUND: The anatomical variations of the coeliac trunk are due to developmental changes in the ventral segmental arteries. Multidetector computed tomography (MDCT) has been used to investigate vascular anatomy for scientific and diagnostic purposes. These studies allow for much larger sample sizes than traditional cadaveric studies. The aim of this research was to isolate rare anatomical variants of the coeliac trunk and emphasize their clinical significance. MATERIALS AND METHODS: A descriptive, retrospective study was carried out on MDCT angiographies performed from January 2020 till March 2020 in Polish patients. Coeliac trunk was studied and normal and anatomical variations were identified. RESULTS: Out of total 350 patients, hepatogastrosplenic trunk was predominant. However, we observed: coeliaco-mesenteric and hepatogastric trunk type, hepatic artery variations and coeliac axis stenosis with collateral mesenteric circulation. CONCLUSIONS: Rare variations of the coeliac trunk should always be anticipated before radiological and surgical interventions. Knowledge of unusual coeliac trunk anatomy is important in hepatopancreatobiliary surgery, transplantology, and interventional radiology.

Variations in the configuration of the celiac trunk among South Africans: clinical relevance / Variaciones en la configuración del tronco celíaco en sudafricanos: relevancia clínica

SUMMARY: The celiac trunk is the first major unpaired branch of the abdominal aorta found at the twelfth vertebral level (T12). It gives off branches supplying the spleen, liver and the stomach. However, the branching patterns of the celiac trunk tend to vary by population throughout the world. We sought to investigate the branching patterns of the celiac trunk in a South African Caucasian sample. The celiac trunk was assessed by visual observation in 66 dissected bodies comprised of both males (n= 30) and females (n=36). These samples were obtained at the School of Anatomical Sciences, University of the Witwatersrand, Johannesburg. The celiac trunk arose directly from the abdominal aorta in all cases, with none connected to the superior mesenteric artery. We observed celiac trunk trifurcation in 84.84 % of the sample, although a celiac trunk with four branches was observed in 10.61 %. Bifurcation into the common hepatic and splenic arteries forming a hepatosplenic trunk (2 females) or into the left gastric artery and splenic artery forming a splenogastric trunk (1 male) was also observed. The results are largely comparable with other studies in Caucasians, showing a high rate of celiac trunk trifurcation (above 75 %). Our sample exhibited fewer variations than reported in previous studies worldwide. Therefore, a larger study with more samples may be required in the future to ascertain all the existing celiac trunk branching patterns in the South African Caucasian population.

RESUMEN: El tronco celíaco es la primera rama principal de la parte abdominal de la aorta en el nivel de la duodécima vértebra torácica (T12), con ramas que irrigan el bazo, el hígado y el estómago. Sin embargo a nivel mundial, las ramificaciones del tronco celíaco tienden a variar según la población. En este estudio se investigaron los patrones de ramificación del tronco celíaco en una muestra caucásica sudafricana. El tronco celíaco se analizó mediante observación visual en 66 cuerpos disecados compuestos por hombres (n = 30) y mujeres (n = 36). Estas muestras se obtuvieron en la Facultad de Ciencias Anatómicas de la Universidad de Witwatersrand, Johannesburgo. El tronco celíaco surgió directamente de la parte abdominal de la aorta en todos los casos, sin que ninguno estuviera unido a la arteria mesentérica superior. Se observó trifurcación del tronco celíaco en el 84,84 % de la muestra, aunque en el 10,61 % se observó un tronco celíaco con cuatro ramas. También se observó bifurcación en las arterias hepática y esplénica común formando un tronco hepatoesplénico (2 mujeres) o en la arteria gástrica izquierda y la arteria esplénica formando un tronco esplenogástrico (1 hombre). Los resultados son comparables con otros estudios en caucásicos que muestran una alta tasa de trifurcación del tronco celíaco (mayor al 75%). Nuestra muestra presentó menos variaciones que las reportadas en estudios previos. Por lo tanto, es posible que se requieran estudios más amplios con más muestras en el futuro, para determinar todos los patrones de ramificación del tronco celíaco en la población caucásica sudafricana.

ANATOMICAL VARIATIONS OF THE SUPERIOR MESENTERIC ARTERY AND ITS CLINICAL AND SURGICAL IMPLICATIONS IN HUMANS.

INTRODUCTION: Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical variations in this vessel contribute to problems in the formation and/or absorption of this part of the intestine and its absence has been recognized as the cause of congenital duodenojejunal atresia. OBJECTIVE: To analyze SMA anatomical variations in humans and the possible associated clinical and surgical implications. METHODS: This is a systematic review of papers indexed in PubMed, SciELO, Springerlink, Science Direct, Lilacs, and Latindex databases. The search was performed by two independent reviewers between September and December 2018. Original studies involving SMA variations in humans were included. SMA presence/absence, level, place of origin and its terminal branches were considered. RESULTS: At the end of the search, 18 studies were selected, characterized as for the sample, method to evaluate the anatomical structure and main results. The most common type of variation was when SMA originated from the right hepatic artery (6.13%). Two studies (11.11%) evidenced the inferior mesenteric artery originating from the SMA, whereas other two (11.11%) found the SMA sharing the same origin of the celiac trunk. CONCLUSION: SMA variations are not uncommon findings and their reports evidenced through the scientific literature demonstrate a great role for the development of important clinical conditions, making knowledge about this subject relevant to surgeons and professionals working in this area.

Angiotomografía de la arteria cística en preoperatorio y comorbilidad en colecistectomía laparoscópica por colelitiasis / Angiotomography of the cystic artery in preoperative and comorbidity in laparoscopic cholecystectomy for cholelithiasis

La colecistectomía laparoscópica es el tratamiento de elección de la colelitiasis; sin embargo, se acompaña de comorbilidades y no está exenta de complicaciones mayores que pueden ser letales; la identificación del trígono cistohepático con disección y ligadura de la arteria cística son pasos obligatorios de la cirugía; la identificación de las variaciones de la arteria cística y los conductos biliares pueden minimizar las eventuales complicaciones. Al protocolo preoperatorio se implementó una angiotomografía con Tomógrafo Siemens Somatón Sensation ® de 64 cortes para identificar la arteria cística en pacientes con colelitiasis de la Unidad de Cirugía General del Hospital de Especialidades Teodoro Maldonado Carbo IESS de Guayaquil. Se escogieron 60 pacientes femeninos en forma aleatoria (edades 19-70 años, promedio 44,25 años) y la muestra se dividió en dos grupos de 30; al grupo estudio se aplicó angiotomografía hasta un mes antes de la cirugía y al grupo control se le aplicó el protocolo convencional. Se evaluó morbilidades relacionadas con: hemorragia operatoria por lesión de la arteria cística y en el posoperatorio: infección de herida operatoria, íleo y drenaje. La angiotomografía permitió identificar la arteria cística en el preoperatorio y contribuyó a disminuir comorbilidades que acompañan a la colecistectomía laparoscópica.

Laparoscopic cholecystectomy is the treatment of cholelithiasis of choice; however, it is accompanied by comorbidities and is not exempt from major complications that can be lethal; the identification of the cystohepatic trigone with dissection and ligation of the cystic artery are mandatory steps of surgery; the identification of the variations of the cystic artery and the bile ducts can minimize the possible complications. The preoperative protocol was implemented with an angiotomography with Siemens Somatón Sensation ® 64-slice Tomograph to identify the cystic artery in patients with cholelithiasis of the General Surgery Unit of the Teodoro Maldonado Carbo IESS Specialty Hospital of Guayaquil. 60 female patients were chosen at random (ages 19 -70 years, average 44.25 years) and the sample was divided into two groups of 30; Angiotomography was applied to the study group up to one month before surgery and the conventional protocol was applied to the control group. Morbidities related to: operative haemorrhage due to cystic artery and postoperative injury: operative wound infection, ileus and drainage were evaluated. Angiotomography allowed to identify the cystic artery in the preoperative period and contributed to decrease comorbidities that accompany laparoscopic cholecystectomy.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

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.

Hepatic Artery Variations in a Sample of Pakistani Population.

OBJECTIVE: To identify the frequency of different arterial variants of common hepatic artery (CHA) overview identified at abdominal CT angiography (CTA) performed in a large series of patients undergoing CT scans for various reasons. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Surgical Oncology and Radiology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan, from October 2016 to September 2018. METHODOLOGY: Findings in randomly selected 1000 patients who underwent CTA were retrospectively evaluated. The pattern of aortic origin of branches of the celiac trunk and superior mesenteric arteries was analysed. The CHA anatomy was then investigated. Hepatic artery anomalies were classified by the Hiatt's method. RESULTS: There were 629 males and 371 females with a median age of 54 years. Type 1 variation (normal anatomy) was seen in 644 patients. Type 2 variation (left hepatic artery, LHA, aberrations), was seen in 135 patients. LHA was seen arising from left gastric artery or common hepatic artery (CHA) in most of the cases. One patient had a replaced LHA from superior mesenteric artery (SMA). Sixteen patients had an accessory LHA and 119 had a replaced LHA. Type 3 variation (unusual anatomy of right hepatic artery, RHA) was seen in 121 patients, 7 patients had an accessory and 114 had a replaced RHA . The replaced or accessory right hepatic artery originated anywhere from SMA, celiac trunk, aorta, CHA or gastroduodenal artery (GDA). Type 4 variation (unsual origin of both RHA and LHA) was seen in 73 patients. Type 5 variation (CHA arising from SMA) was seen in 23 patients. Type 6 variation (CHA arising directly from aorta) was seen in four patients. CONCLUSION: Arterial variations are common in our population of patients. A detailed understanding and knowledge of these variations is necessary for surgeons and radiologists to avoid any inadvertent injuries during various procedures.