The Internet Journal of Gastroenterology ISPUB.COM Volume 11 Number 1

Evaluation Of Branching Pattern Of Hepatic Artery G Nigam, R Lalwani, D Agrawal, K Chauhan

Citation G Nigam, R Lalwani, D Agrawal, K Chauhan. Evaluation Of Branching Pattern Of Hepatic Artery. The Internet Journal of Gastroenterology. 2012 Volume 11 Number 1.

Abstract The incidence of normal hepatic arterial anatomy ranges between approximately 50-80%1-6 of individuals. Knowing anomalous origin of hepatic arteries is important for successful cholecystectomy, hepatobiliary and liver transplant surgery. The present work is a descriptive study which emphasizes to document the normal anatomy and different variations of extra hepatic biliary apparatus and was conducted in Department of Surgery and Anatomy, LLRM Medical College, Meerut and SIMS, Hapur. The study revealed that in all cases, the division of proper hepatic artery was extra-hepatic, of which 92% the point of division was proximal to the point of union of hepatic duct, whereas in 8% cases the point of division was higher. In 86%, the right hepatic artery was dorsal to the common hepatic duct. In 4% cases the artery crossed ventral to common hepatic duct. In 93.5% cases branching pattern of common hepatic artery was normal, 1.5% cases showed trifurcation of common hepatic artery with absence of proper hepatic artery, and aberrant or accessory hepatic artery was present in 5% cases. CONCLUSION: familiarity with vascular Anatomy of sub hepatic region is useful for planning and conduct of radiological as well as surgical procedures of upper abdomen including laparoscopic operations of biliary tract.

INTRODUCTION undergoing hepatobiliary surgery, after informed consent, in Knowledge of variations of CHA may be important in the Department of Surgery and on 30 cadavers in the cholecystectomy, pancreaticoduodenectomy, as well as Department of Anatomy, LLRM Medical College Meerut, during hepatic artery infusion chemotherapy. Volpe et al7 and Sarswathi institute of Medical Sciences, Hapur during reported that injuries to hepatic arterial supply are more September 2004 to May 2011. 9 cases were excluded as they likely to be involved in pancreaticoduodenectomy, shared malignant changes and altered HBA. For the especially in the region of porta hepatis. The presence of cadaveric study, the structures of the extra hepatic biliary variations of the normal hepatic artery anatomy is found in apparatus and vascular system were carefully cleaned and 50 to 80% patients.1-6. These variations may predispose variations systematically observed. For surgeries of open patients to inadvertent injury during open surgical cholecystectomy right paramedian incision was used and the procedures or percutaneous interventions. The aim of this components of extra hepatic biliary apparatus were study was to study the branching pattern and surgical in situ examined. relation of hepatic artery. OBSERVATION Common hepatic artery arises from celiac trunk and divides The proper hepatic artery divided into its terminal branches into gastro duodenal and hepatic artery proper. Hepatic extrahepatically, in all the cases. In 92% i.e. 73 cases, the artery proper divides into left and right hepatic artery point of division of proper hepatic artery was lying proximal (Williams et al., 1996)8. Aberrant left hepatic artery may to the point of union of hepatic ducts and the division of arise from the left gastric/ celiac trunk directly / right hepatic portal vein. However, in 8% i.e. 7 cases the division of / splenic artery / superior mesenteric/ gastro duodenal or proper hepatic artery was closer to porta hepatis i.e. distal to aorta (Hollinshed and Rosse. 1985)9. A new emphasis is the union of hepatic ducts and the division of portal vein given to this by the introduction of liver transplantation (figure :1). hence the present study. In 78% i.e. 63 cases, the proper hepatic artery was seen to lie MATERIAL AND METHOD ventral to portal vein (figure 2a) , in 18% i.e. 14 cases to the The present study was conducted on 59 individuals left of portal vein (figure 2b), and to the right of portal vein in 4% i.e. 3 cases (figure 2c). The proper hepatic artery was

1 of 8 Evaluation Of Branching Pattern Of Hepatic Artery found to lie to the left of duct system in 96% i.e. of Figure 1 specimens and to the right in 4% cases. Figure 1: PHA divides at Porta Hepatitis

The right hepatic artery was found to enter the cysto-hepatic triangle; by passing dorsal to the common hepatic duct in 86% i.e. 69 cases (figure 3b). In 4% i.e. 3 cases the artery crossed ventral to common hepatic duct (figure 3a & 3c) and then turned upward, between the cystic and right hepatic ducts to enter the right lobe of liver. However in 10% i.e. 8 cases, the right hepatic artery was situated to the right of common hepatic duct.

Regarding the position of right hepatic artery, in the cysto- hepatic triangle, most frequently i.e. in 80% i.e. 64 of cases, it lies midway between cystic duct and right hepatic duct, next common position of the artery is close to cystic duct in 15% i.e. 12 cases and least frequently, the artery lies close to the right hepatic duct in 5% i.e. 4 of cases (figure 3a)

In majority of cases (75% i.e. 60 cases), the right hepatic artery was found to lie midway between cystic duct and right hepatic duct. The artery was seen to run close to cystic duct in 20% i.e. 16 cases and close to right hepatic duct in 5% i.e. 4 cases (figure 4).

In 93.5% i.e. 75 cases branching pattern of common hepatic artery was normal, but In one case (i.e. 1.5%) proper hepatic artery was absent, and common hepatic artery trifurcated into right and left hepatic artery and gastroduodenal artery (figure 5). In 5% i.e. 4 cases left & right aberrant hepatic artery was found, left aberrant hepatic artery was arising from proper hepatic artery and ran to supply the caudate lobe & right aberrant hepatic artery arose from right hepatic artery to supply the right lobe (figure 6). Right & Left aberrant hepatic artery was accessory because both right & left hepatic arteries were of normal origin, i.e. both lobes of liver had also received normal supply of blood. In one case aberrant left hepatic artery was arising from common hepatic artery to supply the caudate lobe.

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Figure 2 Figure 3 Figure 2a: PHA ventral to PV (78%) Figure 2b: PHA left to PV (18%)

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Figure 4 Figure 5 Figure 2c: PHA right to PV (4%) Figure 3a: RHA ventral to CHD (4%)

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Figure 6 Figure 7 Figure 3b: RHA dorsal to CHD (86%) Figure 3c: Showing the Right Hepatic Artery ventral to the Common Hepatic Duct. (CHD-Common Hepatic Duct; CD- Cystic Duct; CBD- Common Bile Duct; GB- Gall Bladder; LHA- Left Hepatic Artert; RHA- Right Hepatic Artery; PHA- Proper Hepatic Artery; GDA- Gastro Duodenal Artery; RAHA- Right accessory hepatic artery; LAHA- Left accessory Hepatic Artery;)

Figure 8 Figure 4: RHA in relation to CD & RHD

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Figure 9 hepatic duct, whereas in 8% cases the point of division was Figure 5: Shows Trifurcation of common hepatic artery. higher, these findings were well in accordance with the (BD- Bile Duct; LHA – Left Hepatic Artery; RHA- Right reports of Almenar-Garcia (1993)10. Hepatic Artery; CHA- Common Hepatic Artery; GDA- Gastro Duodenal Artery; LGA- Left Gastric Artery; CT- In the present study, the proper hepatic artery was seen to lie Coeliac Trunk; SA- Splenic Srter ventral to portal vein and to the left of duct system, in majority of specimens. This finding is quite in agreement with the observation mentioned in the report11-12.

According to Daseler et al, (1947)13, in cysto-hepatic triangle, common hepatic duct was dorsal to right hepatic artery in about 20% cases which is quite higher than the present study where the same was observed in 10% of cases.

In the cysto-hepatic triangle, the close contact of right hepatic artery and cystic duct is encountered in 20% of the present series, a relationship found in 50% cases as reported earlier by Thompson (1933)14. This finding is of importance in hepatobiliary surgery.

In present study, total 6.5% variation of branching pattern of the common hepatic artery was observed of which 5% were cases of aberrant or accessory hepatic artery and 1.5% cases of trifurcation of common hepatic artery with absence of Figure 10 proper hepatic artery .Whereas as much as 40% of the total Figure 6: Showing Accesory Hepatic Artery arising from variations of branching pattern of the common hepatic artery Common Hepatic Artery. (CBD- Common Bile Duct; CD- 15 have been described by Michels (1953) and 45% by Baum Cystic Duct; GB- Gall Bladder; LHA- Left Hepatic Artery; 16 1 RHA- Right Hepatic Artery; PHA- Proper Hepatic Artery; (1983) . Abdullah et al. (2006) studied 932 cases of liver GDA- Gastro Duodenal Artery; AHA- Accessory Hepatic transplantation and reported that normal hepatic artery Artery;) distribution was found in 635 cases (68.1%). Variations of hepatic artery were detected in 297 subjects (31.9%) and Gruttadauria et al. (2001)4 studied 701 patients and encountered hepatic artery anomalies in 42%.

Presence of both accessory right and left hepatic arteries in conjunction with a proper hepatic artery has been described with a 1% incidence by Almenar-Garcia et al(1993)10. In his study, Gruttadauria et al. (2001)4 observed the most common anomaly was a replaced/accessory RHA arising from the SMA in 15% of cases; aberrant hepatic artery may be accessory or replacing artery. If an aberrant artery supplies a lobe of liver which receives also a supply from a hepatic artery of normal origin it is known as an aberrant accessory artery. If however it constitutes a sole blood supply to a lobe of liver, it is known as aberrant replacing artery since it replaces the normal hepatic artery. DISCUSSION In present study, in all cases proper hepatic artery divided The literature suggests that these variations can be explained 17S into its terminal branches extrahepatically, of which 92% the in terms of developmental basis . During development, the point of division was proximal to the point of union of extra hepatic biliary system arises from an intestinal

6 of 8 Evaluation Of Branching Pattern Of Hepatic Artery diverticulum, which carries blood supply from branches of 3. Santis De M, Ariosi P, Calo GF, Romagnoli R. Hepatic arterial vascular anatomy and its variants. Radiol Med. 2000; aorta, celiac trunk and superior mesenteric arteries. As the 100:145-51. development progresses, most of these vessels are 4. Gruttadauria S, Foglieni CS, Doria C, Luca A, Lauro A, disappeared and pattern of the disappearance is highly Marino IR. The hepatic artery in liver transplantation and surgery: vascular anomalies in 701 cases. Clin variable. This explains the reason for the sub hepatic Transplant.2001; 15:359-63. variations. The surgeon and interventional radiologists need 5. Jones RM, Hardy KJ. The hepatic artery: a reminder of surgical anatomy. J R Coll Surg Edinb. 2001; 46:168-70. to be aware of the possibility for such anatomical variations 6. Peschaud F, El Hajjam M, Malafosse R, et al. A common in order to avoid potentially disastrous complication. hepatic artery passing in front of the portal vein. Surg Radiol Anat. 2006;28:202-5. CONCLUSION 7. Volpe CM, Peterson S, Hoover EL, Doerr RJ. Justification for visceral angiography prior to The present was a random study conducted to observe the pancreaticoduodenectomy. Am Surg. 1998; 64:758-61. arterial pattern supplying the extra hepatic biliary apparatus 8. Williams PL, Bannster LH, Berry M, et al (1996) Gray’s anatomy. 38th Edition. London: Churchill Livingstone. in the western u.p. population but still further research 1548-1553. continuing in this field. A good knowledge of arterial system 9. Hollinshed H, Rosse C (1985) Text book of Anatomy. 4th Edition. Philadelphia: Harper and Row. 324-640. of liver and extra hepatic biliary apparatus, distribution and 10. Almenar-Garcia V, Sanchez del Campo F, Puchadesorts possible anatomical variation is important for surgeons, A, Cnt Gomis A, Correa Lacarcel J. One further case of radiologists and clinicians as it is significant in liver unusual origin of three hepatic arteries. Surg Radiol Anat 1993; 15155-57. transplantation in order for the vascularity not to be 11. Hollinshed WH. Anatomy for surgeons, Vol. 2, second disturbed and necrosis of liver parenchyma postoperatively, edition. New York; Harper and Row, 1971; 345-62. 12. Gabriel A Kune. The Anatomical Basis of Liver Surgery. nonstablishment of continuity in time of reconstruction is Aust NZ J S URG 1969;30(2): 117-26. important because of post operative complication such as 13. Daseler, E.H. Anson, B.J. Hambley, W.C. and Reimann, acute liver failure which can augment morbidity and A.F. The cystic artery and constituents of the hepatic pedicle: A study of 500 specimens. Surg. Gynae. & Obst. mortality 85:47, 1947. 14. Thompson IM. On the arteries and ducts in the hepatic References pedicle. Univ Calif Press Anat 1933; 1:35. 15. Michels NA. Variation anatomy of the hepatic, cystic 1. Abdullah SS, Mabrut JY, Garbit V, et al. Anatomical and retro duodenal artery. Arch Surg 1953; 66:20-34. variations of the hepatic artery: study of 932 cases in liver 16. Baum S. Hepatic arteriography. In: Abrams HL, ed. transplantation.Surg Radiol Anat. 2006; 28:468-73. Abrams, angiography: vascular and interventional radiology. 2. Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Boston: Little Brown, 1983; 1479-1503. Brown KT. Variant hepatic arterial anatomy revisited: digital 17. Tharao MK, Saidi H, Kitunguu P, Julius OA. Variant subtraction angiography performed in 600 patients. anatomy of the hepatic artery in adult Kenyans. Eur J Anat. Radiology. 2002; 224:542-7. 2007; 11: 155–161.

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Author Information Gulzari Lal Nigam Lecturer, Department Of Anatomy, LLRM Medical College

Rekha Lalwani Assistant Professor, Department Of Anatomy, LLRM Medical College

Dushyant Agrawal Lecturer, Department Of Anatomy, LLRM Medical College

Ketu Chauhan Lecturer, Department Of Anatomy, LLRM Medical College

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