Hilar Anatomy in 3035 Living Liver Donors: A Novel Classification for Donor Surgery and Suitability, Hepatic Surgeries, and Hepatobiliary Interventions.

BACKGROUND: This study examines the vascular and biliary variations in 3035 liver donors. We propose a novel classification of hepatic arteries, portal veins, and bile ducts and clinically relevant donor classification. METHODS: Preoperative imaging and operative details of 3035 donors from 2005 to 2020 were reviewed. Hilar anatomical variations were identified and grouped on the basis of incidence and clinical relevance. RESULTS: Hilar structures are classified according to the numbers supplying or draining the graft: for the hepatic artery, right (R) and left (L), RA1/LA1 (1 artery), RA2/LA2 (2 arteries), and RA3/LA3 (3 arteries), respectively, further defined on the basis of the inflow trunk into C (for common hepatic artery), S (for superior mesenteric artery), and L (for left gastric artery); for the portal vein, RP1 (1 vein) and RP2 (2 veins) for the right lobe; and for the hepatic duct, RB1/LB1 (1 duct), RB2/LB2 (2 ducts), RB3 (3 right ducts), and RB4 (4 right ducts). Donors were classified on the basis of anatomical variations into 3 groups: class 1 and class 2 donors, who can donate liver with acceptable risks, and class 3 donors, who are high-risk donors because they are anatomically unacceptable ( Figures S1 to S4, SDC , http://links.lww.com/TP/C918 ). CONCLUSIONS: Defining hilar anatomical variations and donor grouping into anatomy-based clinical classes helps in operative planning of donors, hepatobiliary surgeries, and interventional procedures.

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.

Liver Anatomy 2.0 Quiz: Test Your Knowledge.

The liver is one the largest organs in the abdomen and the most frequent site of metastases for gastrointestinal tumors. Surgery on this complex and highly vascularized organ can be associated with high morbidity even in experienced hands. A thorough understanding of liver anatomy is key to approaching liver surgery with confidence and preventing complications. The aim of this quiz is to provide an active learning tool for a comprehensive understanding of liver anatomy and its integration into clinical practice.

Deceased Donor Liver Transplantation: Techniques and Surgical Anatomy.

Deceased liver donor transplantation is increasing in prevalence resulting in larger volumes of posttransplant imaging studies. Radiologists should familiarize themselves with the spectrum of normal posttransplant anatomy. The key findings can be categorized into 4 systems reconstructed during surgery: hepatic venous, portal venous, hepatic arterial, and biliary ductal systems. Here we discuss the imaging findings seen with the most common surgical techniques, those that can be misidentified as complications, and some less common variations resulting from different surgical techniques.

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.

Identification of Variation in the Extrahepatic Arterial System of Thai Cadavers / Identificación de la Variación en el Sistema Arterial Extrahepático de Cadáveres Tailandeses

SUMMARY: Liver transplantation (LT) is the treatment of choice for decompensated liver cirrhosis. In the LT procedure, an adequate arterial supply is required for anastomosis to prevent postoperative necrosis and maintain hepatic parenchymal functions. The extrahepatic arterial system is primarily responsible for carrying oxygenated blood from the heart, 25 % of total cardiac output. Normally, the celiac trunk gives off the common hepatic artery. The common hepatic artery branches into the hepatic artery proper and supplies blood to the hepatic parenchyma. Recognizing the anatomical variations of the hepatic artery proper is essential for the planning and implementation of LT. The extrahepatic arterial variations are hard to study in live humans because of the limitations of human rights. Studying cadavers can solve this problem. This study investigates the distribution of normal, accessory, and replaced hepatic arteries proper by dissecting Thai cadavers (n = 152; males = 82 and females = 70) in the Gross Anatomy Laboratory at the Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University. The cadavers were preserved in a 10 % formaldehyde solution. The exclusion criteria for liver specimens were cirrhosis, liver carcinoma, including hepatocellular carcinoma and cholangiocarcinoma, and other liver masses. Accordingly, the extrahepatic arterial system was conventionally dissected and identified at the porta hepatis. The extrahepatic arterial system was identified and documented in terms of features of normal distribution and variations, such as accessory or replaced hepatic arteries. There were 75 % normal type, 18.42 % accessory left hepatic arteries (aLHA), 1.32 % replaced left hepatic arteries (rLHA), 0.66 % accessory right hepatic arteries (aRHA), 1.32 % of replaced right hepatic arteries (rRHA), 1.97 % of aLHA and aRHA, and 1.32 % aortic type. The identification of variations in the hepatic artery system is essential to detection of distribution patterns. This knowledge is crucial for promoting LT.

El trasplante hepático (TH) es el tratamiento de elección para la cirrosis hepática descompensada. En el procedimiento de TH, se requiere un suministro arterial adecuado para la anastomosis para prevenir la necrosis postoperatoria y mantener las funciones del parénquima hepático. El sistema arterial extrahepático es el principal responsable de transportar sangre oxigenada desde el corazón, el 25 % del gasto cardíaco total. Normalmente, el tronco celíaco da origen a la arteria hepática común. La arteria hepática común se ramifica en la arteria hepática propia y suministra sangre al parénquima hepático. Reconocer las variaciones anatómicas de la arteria hepática es fundamental para la planificación e implementación del TH. Las variaciones arteriales extrahepáticas son difíciles de estudiar en humanos vivos debido a las limitaciones de los derechos humanos. El estudio de cadáveres puede resolver este problema. Este estudio investiga la distribución de las arterias hepáticas normales, accesorias y aberrantes mediante la disección de cadáveres tailandeses (n = 152; hombres = 82 y mujeres = 70) en el Laboratorio de Anatomía Macroscópica del Departamento de Anatomía, Facultad de Medicina del Hospital Siriraj, Mahidol. Los cadáveres se conservaron en una solución de formaldehído al 10 %. Los criterios de exclusión para las muestras de hígado fueron cirrosis, carcinoma hepático, incluidos el carcinoma hepatocelular y el colangiocarcinoma, y otras masas hepáticas. En consecuencia, el sistema arterial extrahepático se diseccionó e identificó convencionalmente en el hilio hepático. El sistema arterial extrahepático se identificó y documentó en términos de características de distribución normal y variaciones, como arterias hepáticas accesorias. Hubo 75 % tipo normal, 18,42 % arterias hepáticas izquierdas accesorias (aLHA), 1,32 % arterias hepáticas izquierdas aberrantes (LHAr), 0,66 % arterias hepáticas derechas accesorias (aRHA), 1,32 % arterias hepáticas derechas aberrantes (ARHr), 1,97 % de aLHA y aRHA, y 1,32 % de tipo aórtico. La identificación de variaciones en el sistema de la arteria hepática es esencial para la detección de patrones de distribución. Este conocimiento es crucial para promover LT.

Challenging Orthodoxy: beyond the Critical View of Safety.

BACKGROUND: The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies. METHODS: We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities. RESULTS: There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery. CONCLUSION: Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD.

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.

Surgical anatomy of hepatic arteries from its origin to segmental branching: A 500 cases CT study.

BACKGROUND: The aim of this study was to present an overview of variations of the hepatic artery from the origin to the segmental branching. METHODS: Abdominal Computed Tomography performed on consecutive patients in our tertiary center between 2019 and 2020 were analyzed. Hepatic arterial branching and its relationship to the portal veins were reported. RESULTS: Out of 500 imaging, 16 anatomic patterns were found for the origin of hepatic artery, with 65.6% conventional origin at celiac axis (n = 328); 10 patterns for the left hepatic artery, 23 for segment IV artery, and more than 21 for the right hepatic artery (RHA), with conventional branching in respectively 66.8%, 39.6% and in 46.4% of patients. Conventional anatomy from celiac axis to segmental branching was found in 10.4% of patients. CONCLUSION: Dedicated thin-section imaging appears to be essential for preoperative planning in liver surgery, given the high variability of arterial distribution and their surgical implications.

Morphometric analysis of the human common hepatic artery reveals a rich and accessible target for sympathetic liver denervation.

This study quantified the distribution of nerves and adjacent anatomies surrounding human common hepatic artery (CHA) as guidance for catheter based denervation. CHA collected from cadaveric human donors (n = 20) were histologically evaluated and periarterial dimensions and distributions of nerves, lymph nodes, pancreas and blood vessels quantified by digital morphometry. Nerve abundance decreased significantly with distance from the aortic ostium (P < 0.0001) and was higher in the Superior/Inferior compared to the Anterior/Posterior quadrants (P = 0.014). In each locational group, nerves were absent from the artery wall, and starting 0.5-1.0 mm from the lumen exhibited a first order dependence on radial distance, fully defined by the median distance. Median subject-averaged nerve distance to the lumen was 2.75 mm, ranging from 2.1-3.1 mm in different arterial segments and quadrants and 2.0-3.5 mm in individuals. Inter-individual variance was high, with certain individuals exhibiting 50th and 75th nerve distances of, respectively, 3.5 and 6.5 mm The pancreas rarely approached within 4 mm of the lumen proximally and 2.5 mm more distally. The data indicate that the CHA is a rich and accessible target for sympathetic denervation regardless of sex and diabetes, with efficacy and safety most optimally balanced proximally.

Unusual anatomical variations of the hepatic arteries and bile ducts: What are the surgical implications.

Introduction: The knowledge of anatomy is essential for surgical safety and impacts positively on patients' outcomes. Surgeons operating on the liver and bile ducts should keep in mind the normal anatomy and its variations as the latter are common. Case Presentation: We conducted a structured surgical dissection course of the supra-colic compartment of the abdominal cavity on 2nd and 3rd October 2020. While dissecting a 46years-old male cadaver, we encountered unusual anatomical variations of the hepatic arterial branching, the biliary tree, and arterial supply to the common bile duct. The common hepatic artery was dividing into two branches: a common short trunk for the left hepatic artery and the right gastric artery (hepato-gastric trunk) and a common trunk for the right hepatic artery and gastroduodenal artery (hepato-gastroduodenal trunk). The right hepatic duct was duplicated with a main right hepatic duct and an additional smaller duct. The bile duct was supplied by an artery coming from the abdominal aorta. Conclusion: We described three unusual anatomical variations: a variation of the hepatic arteries branching pattern, an aberrant right hepatic duct, and blood supply to the bile duct from the abdominal aorta. Surgeons should be aware of these rare variations.

Anatomical variations of the hepatic artery: a closer view of rare unclassified variants.

BACKGROUND: Defining the hepatic artery anatomy is of great importance for both surgeons and radiologists. Michel classification was designed to classify hepatic artery variations. Nevertheless, there are variations that do not fit into this classification. In this study, we aim to define the incidence of all variations in a healthy liver donor by reviewing their computed tomography (CT) scan with special emphasis on variations that do not fit in any of the Michel classes. MATERIALS AND METHODS: A retrospective analysis of CT scan of donors and potential liver donors who were evaluated by triphasic CT scan. The CT scans were reviewed independently by a radiologist and two transplant surgeons. Cases that did not fit in any of the Michel classes were classified as class 0. RESULTS: Out of 241 donors, 210 were classified within the Michel classification, of which 60.9% were class I and 9.1% class II. Thirty-one (12.9%) donors classified as class 0. Of which, nine, three, two and three had replaced right hepatic artery from pancreaticoduodenal artery, gastroduodenal artery, aorta and coeliac artery, respectively. Two and six donors had accessory right hepatic artery from pancreaticoduodenal artery and gastroduodenal artery, respectively. Segment 4 artery originated from left and right hepatic artery in 56.8% and 31.9%, respectively. CONCLUSIONS: A great caution should be taken when evaluating the hepatic artery anatomy, clinicians should anticipate and be familiar with the rare unclassified variations of the hepatic artery.

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.

Variaciones anatómicas de la arteria hepática: patrones vasculares observados en 140 hígados de donante cadavérico / Anatomical variations of the hepatic artery: vascular patterns observed in 140 cadaveric donor livers

RESUMEN: El objetivo de este trabajo es analizar las variantes de la arteria hepática observadas en hígados de donantes cadavéricos empleados para trasplante ortotópico de hígado en nuestra población. Se efectuó un estudio retrospectivo de una cohorte de 140 trasplantes entre junio del año 2011 y enero del año 2021. La anatomía vascular arterial de los injertos hepáticos fue clasificada de acuerdo a la descripción de Hiatt. Variante clásica de la arteria hepática - Tipo I: 62 casos (65,7 %). Variante no clásica de la arteria hepática: 48 casos (34,3 %), correspondientes a: Tipo II: 12 casos (8,6 %), Tipo III: 18 casos (12,9 %), Tipo IV: 7 casos (5 %), Tipo V: 10 casos (7,1 %). No se encontró ningún caso de variante Tipo VI. Se halló 1 caso (0,7 %) no descrito en esta clasificación correspondiente a una arteria hepática izquierda accesoria que se originaba de la aorta. El conocimiento preciso de las variaciones más prevalentes, y también de las menos frecuentes, es fundamental para los procedimientos quirúrgicos que se realizan en el abdomen superior.

SUMMARY: The purpose of this article is to analyze the hepatic artery variations observed from the use of cadaveric donor livers for orthotopic transplantation among our population. A retrospective study of a liver transplant cohort including 140 donor livers was conducted between June 2011 and January 2021. The vascular arterial anatomy of the transplanted livers was classified according to Hiatt's classification system. Classic hepatic artery variant: Type I: 62 cases (65.7 %). Non-classic hepatic artery variants: 48 cases (34.3 %), corresponding to: Type II: 12 cases (8.6 %), Type III: 18 cases (12.9 %), Type IV: 7 cases (5 %), Type V: 10 cases (7.1 %). No case of Type VI variant was identified. One case (0.7 %) not included in Hiatt's classification was found, corresponding to an accessory left hepatic artery originating from the aorta. Precise knowledge regarding the most prevalent variations, as well as those that are the least common, is fundamental to upper abdominal surgical procedures.

Prepancreatic common hepatic artery arising from superior mesenteric artery: an exceptional but important finding during pancreaticoduodenectomy.

PURPOSE: The hepato-mesenteric trunk is an extremely rare condition in which the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA). Usually, CHA passes behind the head of the pancreas. A systematic review was performed to provide guidelines for the perioperative management of patients with this anatomical variation who underwent a pancreaticoduodenectomy (PD). A case report was also included. METHODS: A systematic search of the literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. The risk of bias within individual studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Case report was structured according to the CARE guidelines. RESULTS: After an initial selection of 141 titles, 9 articles were included in the study (n = 10 patients). A postoperative surgical complication which required a reintervention occurred only one time. In four patients, CHA had a posterior position relative to pancreas, while in three cases, it was anterior. The remaining three patients had an intrapancreatic course. The CHA was resected in two patients, with an end-to-end reconstruction or using the splenic artery stump. In only three patients, a preoperative multidisciplinary presentation was performed and in four cases, the CHA variation was not described by radiologists in formal CT-scan reports. CONCLUSION: Although there are no definitive guidelines, improvements in the preoperative knowledge of such a rare anatomical variation may ensure better postoperative outcomes, avoiding intraoperative accidents and life-threatening postoperative complications.

Diameter measurements and variations of the hepatic arterial system in multidetector computed tomography images / Mediciones de diámetro y variaciones del sistema arterial hepático en imágenes de tomografía computarizada multidetector

SUMMARY: Liver plays an important role in many events such as bile production, blood filtration and metabolic functions. The liver is supplied by the hepatic arterial system. The hepatic arterial system anatomy has a variable structure and the rate of variation is high. In our study, we aimed to determine the diameters and variation of the arteries supplying the liver with multidetector computed tomography images. In this study, hepatic arterial system variations of 500 cases whose abdominal region was imaged with multi- detector computed tomography were evaluated and the diameters of the related arteries were measured. The mean diameters of classical and variational anatomy were determined in this study. According to mean measurements of classical and variational anatomy were abdominal aorta 21.95 mm, celiac artery 7.2 mm, common hepatic artery 4.3 mm, proper hepatic artery 2.93 mm, right hepatic artery 2.92 mm, left hepatic artery 2.51 mm and abdominal aorta 21.85 mm, celiac artery 6.99 mm, common hepatic artery 5.07 mm, proper hepatic artery 3.83 mm, right hepatic artery 2.87 mm ve left hepatic artery 2.09 mm respectively. When evaluated in terms of variations, 85.6 % of the cases had branching according to Type I, 14.4 % of the cases had different branching patterns. Type III (87.5 %) was the most observed variation among them. As a result of the study, it was determined that the arterial diameters vary according to the state of variation and that the arterial diameter of men are greater than that of women.

RESUMEN: El hígado juega un papel importante en diferentes eventos, tal como la producción de bilis, la filtración de sangre y las funciones metabólicas. El hígado está irrigado por el sistema arterial hepático. La anatomía del sistema arterial hepático tiene una estructura variable y la tasa de variación es alta. En nuestro estudio, nuestro objetivo fue determinar los diámetros y la variación de las arterias que irrigan el hígado con imágenes de tomografía computarizada multidetector. Se evaluaron las variaciones del sistema arterial hepático de 500 casos y se obtuvieron imágenes con tomografía computarizada de detectores múltiples abdominales y se midieron los diámetros de las arterias relacionadas. Se determinaron los diámetros medios de la anatomía clásica y variacional. Según las medidas medias de la anatomía clásica y variacional fueron aorta abdominal 21,95 mm, arteria celíaca 7,2 mm, arteria hepática común 4,3 mm, arteria hepática propia 2,93 mm, arteria hepática derecha 2,92 mm, arteria hepática izquierda arteria 2,51 mm y parte abdominal de la aorta 21,85 mm, arteria celíaca 6,99 mm, arteria hepática común 5,07 mm, arteria hepática propia 3,83 mm, arteria hepática derecha 2,87 mm y arteria hepática izquierda 2,09 respectivamente. Cuando se evaluó en términos de variaciones, el 85,6 % de los casos tenían ramificaciones según el Tipo I, el 14,4 % de los casos tenían diferentes patrones de ramificación. El tipo III (87,5 %) fue la variación más observada entre ellos. Como resultado del estudio, se determinó que los diámetros arteriales varían según el estado de variación y que el diámetro arterial de los hombres es mayor que el de las mujeres.

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.

Conventional hepatic arterial anatomy? Novel findings and insights of a multi-disciplinary hepatic arterial infusion pump program.

INTRODUCTION: Variant hepatic arterial anatomy (vHAA) is thought to occur in 20-30% of patients. Hepatic arterial infusion (HAI) pump placement for liver cancers requires thorough hepatic artery dissection; we sought to compare vHAA identified during pump placement with established dogma. METHODS: Between 2016 and 2020, n = 30 patients received a HAI pump. Intra-operatively identified vHAA was characterized and compared with published data. RESULTS: vHAA was identified in 60% (n = 18) of patients, significantly higher than 19% (3671 of 19013) in the largest published series (P < 0.001). The most common variations were accessory left (n = 12; 40%) and replaced right (n = 6; 20%) hepatic arteries; six (20%) had ≥2 variants. Pre-operative imaging correctly identified 67% of variant hepatic arteries. DISCUSSION: Meticulous operative dissection of the hepatic arterial tree reveals vHAA not captured by imaging or cadaveric dissection. vHAA likely has a higher prevalence than previously reported and should be addressed to optimize therapeutic efficacy of HAI pump therapy.

Hepatic Arterial Variations and Its Implication During Pancreatic Cancer Surgeries.

PURPOSE: Aberrant hepatic artery anatomy is a considerable challenge during pancreatic surgery as it warrants extreme caution for the preservation of vascular supply as well as achievement of R0 resection margin. METHOD: We reviewed the literature about the aberrant anatomical variations of the hepatic artery and its relevance during pancreatoduodenectomy and distal pancreatectomy. RESULT: Preoperative deliberation of peri-pancreatic vascular anatomy using advanced imaging methods is crucial for surgeons. At the same time, intra-operative suspicion and early identification of aberrant anatomy may help to prevent vascular injury and related complications. Yet, vascular reconstruction may be needed in many situations; several techniques like pre-operative embolization provide new options for management in specific situations. CONCLUSION: We have provided here an overview of the anatomical variants of the hepatic artery and their implication during pancreatoduodenectomy and distal pancreatectomy.