Accessory right hepatic artery and aberrant bile duct in the hepatocystic triangle: a rare case with clinical implications

Fat clearance in the hepatocystic triangle during laparoscopic cholecystectomy: Fact or fad? An NIRF-based study

INTRODUCTION

At present, the pre- and postdissection regions during laparoscopic cholecystectomy (LC) are uniformly described by the term "hepatocystic triangle" (HCT). It is unclear whether a distinction needs to be made. An observational study was undertaken to evaluate the predissection hepatocystic region (pre-HCR) and the postdissection hepatocystic region (post-HCR). Also, the dissection-related changes to the contents of the pre-HCR ("proper HCT") were evaluated.

METHODS

A retrospective review of a prospectively maintained database was done. The operative videos of patients who underwent fluorescence-guided surgery from December 2021 to February 2022 were reviewed. Patients with gallstone disease without complications (GSD) were included in the study. Exclusion criteria were acute cholecystitis, choledocholithiasis, biliary pancreatitis, biliary fistulas, and gallbladder wall thickening of ≥3 mm on ultrasonography.

RESULTS

Thirteen patients underwent LC for GSD using standard dissection methods. The boundaries of the pre-HCR were identified before dissection in all patients. The dissection resulted in a quadrangular space lateral to the "proper HCT" in all. The post-HCR contained the undissected "proper-HCT" and the quadrangular space in all. The post-HCR area was 4.4 times that of the pre-HCR (3.2-13.1). The peritoneum over the "proper HCT" was unbreached in all patients, and the target structures were delineated outside of it. A critical view of safety (CVS) was demonstrated outside of the "proper HCT" in all patients.

CONCLUSION

During near-infrared fluorescence-guided LC for GSD, there is no fat clearance in the "HCT." The hepatocystic region before and at the conclusion were distinctly different. The uniform usage of the term "HCT" does not convey this change.

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.

[Modern principles of safety in laparoscopic cholecystectomy]

Laparoscopic cholecystectomy has many advantages over open surgery. Nevertheless, incidence of intraoperative bile duct injury is consistently higher for laparoscopic technique. This review is devoted to modern principles of identifying the anatomical elements in hepatoduodenal ligament and rules for safe tissue dissection in this area. The last ones mainly consist in formation of «critical view of safety» before clipping and transection of tubular structures. The key for «critical view of safety» is mobilization of fatty and fibrous tissues of hepatocystic triangle starting from the lower third of the gallbladder.