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| OJHAS Vol. 16, Issue 2:
(April-June 2017) |
Case Report
Rare Type of Course and Distribution of an Additional Right Hepatic Artery: A Possible Source of Iatrogenic Injury During Hepato-biliary and Pancreatic Surgeries
Authors
Prakashchandra Shetty, Satheesha Nayak B, Melanie Rose D’Souza,
Melaka Manipal Medical College (Manipal Campus). Manipal University, Manipal - 576104, Karnataka, India.
Corresponding Address
Dr. Satheesha Nayak B,
Professor of Anatomy,
Melaka Manipal Medical College (Manipal campus),
Manipal University, Madhav Nagar,
Manipal, Karnataka State, INDIA.
E-mail: nayaksathish@gmail.com
Citation
Shetty P, Nayak SB, D'Souza MR. Rare Type of Course and Distribution of an Additional Right Hepatic Artery: A Possible Source of Iatrogenic Injury During Hepato-biliary and Pancreatic Surgeries Online J Health Allied Scs.
2017;16(2):18. Available at URL:
http://www.ojhas.org/issue62/2017-2-18.html
Submitted: Jan 19, 2017; Accepted: July 14, 2017; Published: July 30, 2017 |
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Abstract: Celiac
artery shows frequent variations in its branching pattern. Knowledge of its possible variations is useful in
gastric, pancreatic and hepato-biliary surgeries. During our dissection classes, we observed a rare variation of
the branching pattern of celiac trunk. It divided normally into its three branches; left gastric, splenic and
common hepatic arteries. Left gastric and splenic arteries were normal in their course and distribution. The
common hepatic artery trifurcated to give hepatic artery proper, gastroduodenal artery and an additional right
hepatic artery. The branching pattern of hepatic artery proper and gastroduodenal arteries was normal. The
additional right hepatic artery gave origin to a right gastric artery and a large pancreatic branch to the head
of the pancreas. It coursed parallel to the bile duct, being on its right side, passed through the Calot’s
triangle and entered the right lobe of liver through the fossa for gall bladder. In the Calot’s triangle, it
gave a cystic branch to the gall bladder. We discuss the clinical importance of this rare variation in this
paper.
Key Words:
Celiac trunk, Hepatic artery, Cystic artery, Bile duct, Calot’s triangle, Common hepatic |
Introduction:
Celiac trunk is the first ventral splanchnic branch of abdominal aorta. It
arises from the aorta as soon as the aorta enters the abdomen through the aortic opening of the diaphragm. It
has a short forward course of about half inch, after which it terminate by dividing into left gastric, splenic
and common hepatic arteries.(1) Celiac trunk shows frequent variations in its branching pattern. Its branches
may come directly from the abdominal aorta (2), or may come as common trunks with other nearby vessels like
superior mesenteric, inferior phrenic or renal arteries. Celiaco-mesenteric trunk (3), Celiaco-mesenterico-phrenic
trunk (4), gastrosplenic trunk (5) and hepato-gastric trunk (6) have been reported in the literature. Knowledge
of the possible variations of branching pattern of celiac trunk is very useful in many surgical procedures in the
upper abdomen. The aim or this case report is the alert the surgeons about the course and branching pattern of a rare
additional right hepatic artery.
Case Report
During our dissection classes for undergraduate medical students, we observed
the following variations in the branching pattern of the celiac trunk in an adult male cadaver aged approximately
70 years. The celiac trunk arose from the abdominal aorta and terminated by dividing into 3 branches; left
gastric, splenic and common hepatic arteries in the usual manner. The course and distribution of splenic and
left gastric arteries was normal. The common hepatic artery however, trifurcated to give hepatic artery proper,
gastroduodenal artery and an additional right hepatic artery (Figure 1). The hepatic artery proper divided
into right and left hepatic arteries, which entered the respective lobes of liver through the porta hepatis.
The right hepatic artery gave a cystic artery just before entering the liver. The gastroduodenal artery
terminated by dividing into right gastroepiploic artery and superior pancreaticoduodenal artery in the usual
manner.
The additional right hepatic artery crossed in front of the bile duct from left to right, just above the first part of the
duodenum. It ascended in the right free margin of the lesser omentum, on the right side of the bile duct, passed through the
Calot’s triangle and entered the right lobe of the liver through the fossa for gall bladder. While crossing the bile duct,
it gave two branches; a right gastric artery which supplied the stomach and a large pancreatic artery which descended behind
the head of the pancreas and supplied the same. Further, while passing through the Calot’s triangle, it gave a cystic artery
which supplied the gall bladder. Thus, the Calot’s triangle in this case had additional right hepatic artery and two cystic
arteries.
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Figure 1. Dissection of the variant branching pattern of celiac trunk showing the additional right hepatic artery (ARHA)
and its branches. (CT – celiac trunk; LGA – left gastric artery; SA – splenic artery; CHA – common hepatic artery; HAP – hepatic artery
proper; RHA – right hepatic artery; LHA – left hepatic artery; CA – cystic artery; GDA – gastroduodenal artery; PA – large
pancreatic artery from the additional right hepatic artery; RGA – right gastric artery; CD – cystic duct; BD – bile duct; GB –
gall bladder; RLL – right lobe of liver; LLL – left lobe of liver) |
Discussion
Close association of celiac trunk and its branches with stomach, pancreas, liver, gall bladder
and spleen makes it a very important surgical landmark. Iatrogenic injuries of celiac trunk branches are common during
surgeries of these organs. More so when there are variations in the branching pattern of the celiac trunk. The hepatic artery
shows many variations. Its trifurcation, higher level of termination, aberrant branches and varied distribution have been
well documented.(7-9) Aberrant right hepatic artery takes origin from superior mesenteric artery some times. In such cases
it ascends up behind the head of the pancreas.(10-12) Presence of additional right hepatic artery is a rare occurrence and
very few cases have been reported about this variation. Badagabettu et al (13) have reported the presence of an additional
right hepatic artery forming a caterpillar hump. Nayak SB et al., have reported the presence of an additional right hepatic
artery which passed behind the bile duct. It gave a cystic artery in the Calot’s triangle. In the current case the
additional right hepatic artery crossed superficial to the lower part of the bile duct, just above the first part of
duodenum. It gave a right gastric artery and a large pancreatic artery while crossing in front of the bile duct. It also
passed through the Calot’s triangle and gave a cystic branch before reaching the liver. The lower part of the additional
right hepatic artery might undergo iatrogenic injuries in pyloric and pancreatic surgeries. Its part in the Calot’s
triangle or its cystic branch might be endangered in laparoscopic cholecystectomy.
Conclusion
A rare additional right hepatic artery has been reported here. There is no report available on
additional right hepatic artery supplying stomach, pancreas and gall bladder. Its course close to duodenum and along the bile
duct, in the Calot’s triangle and entry to the liver through fossa for gall bladder makes it vulnerable surgically.
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