A single-center clinical study of hepatic artery variations in laparoscopic pancreaticoduodenectomy: A retrospective analysis of data from 218 cases

Novel embryological classifications of hepatic arteries based on the relationship between aberrant right hepatic arteries and the middle hepatic artery: A retrospective study of contrast-enhanced computed tomography images

BACKGROUND

Variations in hepatic arteries are frequently encountered during pancreatoduodenecomy. Identifying anomalies, especially the problematic aberrant right hepatic artery (aRHA), is crucial to preventing vascular-related complications. In cases where the middle hepatic artery (MHA) branches from aRHAs, their injury may lead to severe liver ischemia. Nevertheless, there has been little information on whether MHA branches from aRHAs. This study aimed to investigate the relationship between aRHAs and the MHA based on the embryological development of visceral arteries.

METHODS

This retrospective study analyzed contrast-enhanced computed tomography images of 759 patients who underwent hepatobiliary-pancreatic surgery between January 2011 and August 2022. The origin of RHAs and MHA courses were determined using three-dimensional reconstruction. All cases of aRHAs were categorized into those with or without replacement of the left hepatic artery (LHA).

RESULTS

Among the 759 patients, 163 (21.4%) had aRHAs. Five aRHAs patterns were identified: (Type 1) RHA from the gastroduodenal artery (2.7%), (Type 2) RHA from the superior mesenteric artery (SMA) (12.7%), (Type 3) RHA from the celiac axis (2.1%), (Type 4) common hepatic artery (CHA) from the SMA (3.5%), and (Type 5) separate branching of RHA and LHA from the CHA (0.26%). The MHA did not originate from aRHAs in Types 1-3, whereas in Type 4, it branched from either the RHA or LHA.

CONCLUSIONS

Based on the developmental process of hepatic and visceral arteries, branching of the MHA from aRHAs is considered rare. However, preoperative recognition and intraoperative anatomical assessment of aRHAs is essential to avoid injury.

Evaluation of the Educational Quality of the Top 30 Most Viewed Laparoscopic Distal Pancreatectomy Videos on YouTube

Background: Online surgical videos serve as useful adjuncts for surgical training. YouTube is a social media platform increasingly used for education. However, the educational qualities of these videos have not been proven. This study aims to review the topmost 30 viewed videos on laparoscopic distal pancreatectomy (LDP) on YouTube. Methods: A YouTube search was performed on August 1, 2020, using the term "laparoscopic distal pancreatectomy." Inclusion criteria were LDP with or without splenectomy. Exclusion criteria were open or robotic distal pancreatectomy and radical antegrade modular pancreatosplenectomy. To grade the videos, we used a modified version of the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) 24 of the original 37 consensus statements were used in our study. Results: Twenty-nine of the top 30 most viewed videos were included (1 video was a duplicate). The overall mean view count and number of likes were 7195 (range 2322-39,927) and 17 (range 0-108), respectively. Thirteen videos (44.8%) were on LDP with splenic preservation. The mean conformity to the modified LAP-VEGaS was 9.3 (range 4-16) with a mean of 38.8% (range 16.7%-66.7%) of the criteria met. There was weak correlation between the number of views and the number of criteria met (ρ = 0.189, P < .05). Twelve videos (41.4%) described about staple line management, nine videos (31%) about tips and tricks to reduce postoperative pancreatic fistula, including drainage tube management, and three videos (10.3%) identified the common hepatic artery. Videos with no commentary had the lowest mean percentage of criteria met (24.6%). Conclusion: The topmost viewed LDP surgical videos have gaps in meeting the educational needs of a trainee. Video uploaders should be cognizant of the learning needs of surgical trainees.

How to deal with right hepatic artery coming from the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review

BACKGROUND

Anatomical variations in the liver arterial supply are quite common and can affect the surgical strategy when performing a minimally invasive pancreaticoduodenectomy (MIPD). Their presence must be preemptively detected to avoid postoperative liver and biliary complications.

DATA SOURCES

Following the PRISMA guidelines and the Cochrane protocol we conducted a systematic review on the management of an accessory or replaced right hepatic artery (RHA) arising from the superior mesenteric artery when performing an MIPD.

RESULTS

Five studies involving 118 patients were included. The most common reported management of the aberrant RHA was conservative (97.0%); however, patients undergoing aberrant RHA division without reconstruction did not develop liver or biliary complications. No differences in postoperative morbidity or long-term oncological related overall survival were reported in all the included studies when comparing MIPD in patients with standard anatomy to those with aberrant RHA.

CONCLUSIONS

MIPD in patients with aberrant RHA is feasible without increase in morbidity and mortality. As preoperative strategy is crucial, we suggested planning an MIPD with an anomalous RHA focusing on preoperative vascular aberrancy assessment and different strategies to reduce the risk of liver ischemia.

Importance of Anatomical Variation of the Hepatic Artery for Complicated Liver and Pancreatic Surgeries: A Review Emphasizing Origin and Branching

Knowledge of anatomical variations of the hepatic artery from its origin to intrahepatic segmentation is of utmost importance for planning upper abdominal surgeries including liver transplantation, pancreatoduodenectomy, and biliary reconstruction. The origin and branching pattern of the hepatic artery was thoroughly described by the classification of Michels and Hiatt. Some rare variations of the hepatic artery were classified by Kobayashi and Koops. By the use of the multidetector computed tomography (MDCT) technique, the branching pattern of the hepatic artery can be visualized quite accurately. Unawareness of these arterial variations may lead to intraoperative injuries such as necrosis, abscess, and failure of the liver and pancreas. The origin and course of the aberrant hepatic arteries are crucial in the surgical planning of carcinoma of the head of the pancreas and hepatobiliary surgeries. In liver transplant surgeries, to minimize intraoperative bleeding complications and postoperative thrombosis, exact anatomy of the branching of the hepatic artery, its variations and intrahepatic course is of utmost importance. This review discusses variations in the anatomy of the hepatic artery from its origin to branching by the use of advanced imaging techniques and its effect on the liver, pancreatic, biliary and gastric surgeries.

Strategic Approach to Aberrant Hepatic Arterial Anatomy during Laparoscopic Pancreaticoduodenectomy: Technique with Video

BACKGROUND

It is critical for every pancreatic surgeon to determine how to protect the aberrant hepatic artery intraoperatively in order to safely implement laparoscopic pancreatoduodenectomy (LPD). "Artery-first" approaches to LPD are ideal procedures in selected patients with pancreatic head tumors. Here, we described our surgical procedure and experience of aberrant hepatic arterial anatomy-LPD (AHAA-LPD) in a retrospective case series. In this study, we also sought to confirm the implications of the combined SMA-first approach on the perioperative and oncologic outcomes of AHAA-LPD.

METHODS

From January 2021 to April 2022, the authors completed a total of 106 LPDs, of which 24 patients underwent AHAA-LPD. We evaluated the courses of the hepatic artery via preoperative multi-detector computed tomography (MDCT) and classified several meaningful AHAAs. The clinical data of 106 patients who underwent AHAA-LPD and standard LPD were retrospectively analyzed. We compared the technical and oncological outcomes of the combined SMA-first approach, AHAA-LPD, and the concurrent standard LPD.

RESULTS

All the operations were successful. The combined SMA-first approaches were used by the authors to manage 24 resectable AHAA-LPD patients. The mean age of the patients was 58.1 ± 12.1 years; the mean operation time was 362 ± 60.43 min (325-510 min); blood loss was 256 ± 55.72 mL (210-350 mL); the postoperation ALT and AST were 235 ± 25.65 IU/L (184-276 IU/L) and 180 ± 34.43 IU/L (133-245 IU/L); the median postoperative length of stay was 17 days (13.0-26.0 days); the R0 resection rate was 100%. There were no cases of open conversion. The pathology showed free surgical margins. The mean number of dissected lymph nodes was 18 ± 3.5 (14-25); the number of tumor-free margins was 3.43 ± 0.78 mm (2.7-4.3 mm). There were no Clavien-Dindo III-IV classifications or C-grade pancreatic fistulas. The number of lymph node resections was greater in the AHAA-LPD group (18 vs. 15, p < 0.001). Surgical variables (OT) or postoperative complications (POPF, DGE, BL, and PH) showed no significant statistical differences in both groups.

CONCLUSIONS

In performing AHAA-LPD, the combined SMA-first approach for the periadventitial dissection of the distinct aberrant hepatic artery to avoid hepatic artery injury is feasible and safe when performed by a team experienced in minimally invasive pancreatic surgery. The safety and efficacy of this technique need to be confirmed in large-scale-sized, multicenter, prospective randomized controlled studies in the future.

Anatomical variations of the hepatic artery in it's extra hepatic journey: a cadaveric study with its clinical implications

Vascular anomalies are a serendipitous finding during surgeries and diagnostic angiography. Such variations are frequently encountered in the abdominal region. These anomalies are usually asymptomatic but the presence of hepatic arterial variations may lead to injuries of the liver during surgery. The present study was conducted on 35 adult embalmed cadavers, 31 males, 4 females from August 2015 to December 2021 in the Department of Anatomy, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi. In this study of 35 cadavers, we present 3 variants: an accessory right hepatic artery, replaced common hepatic artery, replaced common hepatic artery anastomosis with accessory left hepatic artery and an arc of Buhler. One of our variants has not yielded a precedent in literature search. We have compared these variants with Michels and Hiatt classification. It is known that different variants arise at distinct stages of embryonic development. As specialists in anatomy, we have tried to correlate the variants in our study with their embryological origins.

Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Hepatic vascular anomalies during totally laparoscopic pancreaticoduodenectomy: challenging the challenge

The presence of hepatic vascular anomalies may add challenges to an already difficult surgery such as pancreatoduodenectomy, particularly when performed laparoscopically. Thus, our aim was to assess the impact of an aberrant right hepatic artery (aRHA) on postoperative outcomes during laparoscopic pancreatoduodenectomy (LPD) . Data of patients who underwent LPD were prospectively gathered and retrospectively analyzed. Patients with types III, IV, VI, VII, VIII, and IX anomalies according to Michels' classification were included in the aRHA group and were compared with the remaining patients (nRHA group). 72 patients underwent LPD; 14 of these had an aRHA (19.4%). Except for BMI (p = 0.021), the two groups did not differ in terms of clinico-pathological characteristics. The two groups had similar postoperative complications (p = 0.123), pancreatic fistula (p = 0.790), biliary leakage (p = 0.209), postpancreatectomy hemorrhage (p = 0.790), reoperations (p = 0.416), and mortality (p = 0.312). The median number of lymph nodes harvested was higher in aRHA group (p = 0.032), while R0 resection rate was similar between groups (p = 0.635). At the multivariate analysis, only moderate/high FRS (OR 3.95, p = 0.039) was an independent predictor of postoperative complications. This study suggests that aRHA has no negative impact on surgical and oncological outcomes in patients undergoing LPD.

CT reporting of relevant vascular variations and its implication in pancreatoduodenectomy

Pancreatoduodenectomy (PD) also known as Whipple procedure is done for malignant lesions involving the distal CBD, duodenum, ampulla and pancreatic head. In the absence of peritoneal and distant metastases, resectability of the lesion is mainly determined by the relationship of the lesion with the vascular structures in the vicinity. Vascular variations of the celiac artery branches are common and PD, a complex surgical procedure, becomes more challenging if the vascular variations are present. In borderline resectable lesions advances in neoadjuvant therapies and refined surgical techniques are pushing the boundaries of resection. Extended PD is done in borderline resectable lesions when resection and reconstruction of portal vein involved by the primary mass and dissection of extended lymph nodal stations are intended. In this era where more borderline cases are undergoing surgery, it is essential for the radiologist to understand the procedure and the implications of variations in vascular anatomy. Though there are many radiology literatures available on the diagnostic and resectability criteria related to normal vessel anatomy there are very few on the importance of the variant arterial anatomy. The purpose of this review is to familiarize the readers with these variant vessels which can help the surgeons in their intraoperative identification and consequently improve surgical outcomes.

Application of a surgical nursing cooperation program in laparoscopic pancreaticoduodenectomy

Background

To evaluate the value of programmed surgical nursing in laparoscopic pancreaticoduodenectomy (LPD) and summarize the experience.

Methods

The clinical data of 80 patients who received LPD in Sun Yat-sen Memorial Hospital from January 2017 to December 2018 were analyzed retrospectively. A total of 40 patients were treated with traditional surgical nursing as the control group in the earlier stage. Afterwards, another 40 cases in the experimental group were treated using the surgical nursing program. Operation time, blood loss, and satisfaction of surgeons were analyzed.

Results

In all, 80 cases were successfully completed, and no significant difference was observed in the preoperative data statistics between these two groups (P>0.05). Compared with the control group, the average operation time and the average blood loss of the experimental group were significantly reduced (288.9±11.14 vs. 364.5±10.84 min, P<0.05; 135.3±20.12 vs. 364.8±77.39 mL, P<0.05), and the satisfaction of surgeons was significantly higher (95% vs. 80%, P<0.05).

Conclusions

Skilled execution of nursing cooperation is crucial in LPD. Through appropriate preoperative preparation, gaining mastery operation steps, remaining in sync with surgeons, and perfecting the management details, the surgical nursing cooperation program can improve the satisfaction of the surgeons and make operations more efficient.