Skip to main content
SpringerLink
Log in
SpringerLink
Log in

Intraoperative Injury to Hepatic Arterial Structures

  • Chapter
  • First Online:
Gastrointestinal Surgery

Abstract

The hepatic artery and its branches provide arterial blood to the liver, biliary tract, pancreatic head, and duodenum. Its proximity to vital structures in the porta hepatis, compounded with frequent anatomic variations, make it susceptible to injury during hepatopancreatobiliary surgery. Consequences of loss of hepatic arterial flow range from transient insignificant transaminitis to hepatic necrosis, anastomotic leak, and death. Knowledge of the spectrum of anatomic aberrations, clinical scenarios that determine morbidity, and tools to anticipate, avoid, and manage intraoperative injury can equip surgeons to effectively steer potentially catastrophic situations toward more favorable outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 149.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 199.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Shukla PJ, Barreto SG, Kulkarni A, Nagarajan G, Fingerhut A. Vascular anomalies encountered during pancreatoduodenectomy: do they influence outcomes? Ann Surg Oncol. 2009;17(1):186–93.

    Article  PubMed  Google Scholar 

  2. Chamberlain RS, El-Sedfy A, Rajkumar D. Aberrant hepatic arterial anatomy and the whipple procedure: lessons learned. Am Surg. [Review]. 2011;77(5):517–26.

    PubMed  Google Scholar 

  3. Hann LE, Blumgart LH. Surgical and ragiologic anatomy of the liver, biliary tract, and pancreas. In: Jarnagin WR, editor. Blumgart’s surgery of the liver, pancreas and biliary tract. 5th ed. Philadelphia: Elsevier Saunders; 2012.

    Google Scholar 

  4. Rocha FG. Liver blood flow: physiology, measurement, and clinical relevance. In: Jarnagin WR, editor. Blumgart’s surgery of the liver, pancreas, and biliary tract. 5th ed. Philadelphia: Elsevier Saunders; 2012.

    Google Scholar 

  5. Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg. 1979;66(6):379–84.

    Article  CAS  PubMed  Google Scholar 

  6. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg. 1966;112(3):337–47.

    Article  CAS  PubMed  Google Scholar 

  7. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg. [Review]. 1994;220(1):50–2.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Brown KT. Variant hepatic arterial anatomy revisited: digital subtraction angiography performed in 600 patients. Radiology. 2002;224(2):542–7.

    Article  PubMed  Google Scholar 

  9. Koops A, Wojciechowski B, Broering DC, Adam G, Krupski-Berdien G. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat. 2004;26(3):239–44.

    Article  CAS  PubMed  Google Scholar 

  10. Abdullah SS, Mabrut J-Y, Garbit V, Roche E, Olagne E, Rode A, et al. Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation. Surg Radiol Anat. 2006;28(5):468–73.

    Article  PubMed  Google Scholar 

  11. López-Andújar R, Moya A, Montalvá E, Berenguer M, De Juan M, San Juan F, et al. Lessons learned from anatomic variants of the hepatic artery in 1081 transplanted livers. Liver Transplant. 2007;13(10):1401–4.

    Article  Google Scholar 

  12. Suzuki T, Nakayasu A, Kawabe K, Takeda H, Honjo I. Surgical significance of anatomic variations of the hepatic artery. Am J Surg. 1971;122(4):505–12.

    Article  CAS  PubMed  Google Scholar 

  13. Daly JM, Kemeny N, Oderman P, Botet J. Long-term hepatic arterial infusion chemotherapy. Anatomic considerations, operative technique, and treatment morbidity. Arch Surg. 1984;119(8):936–41.

    Article  CAS  PubMed  Google Scholar 

  14. Rygaard H, Forrest M, Mygind T, Baden H. Anatomic variants of the hepatic arteries. Acta Radiol Diagn (Stockh). 1986;27(4):425–7.

    CAS  Google Scholar 

  15. Chen CY, Lee RC, Tseng HS, Chiang JH, Hwang JI, Teng MM. Normal and variant anatomy of hepatic arteries: angiographic experience. Zhonghua Yi Xue Za Zhi (Taipei). 1998;61(1):17–23.

    CAS  Google Scholar 

  16. De Santis M, Ariosi P, Calo GF, Romagnoli R. Hepatic arterial vascular anatomy and its variants. Radiol Med. 2000;100(3):145–51.

    CAS  PubMed  Google Scholar 

  17. Song S-Y, Chung JW, Yin YH, Jae HJ, Kim H-C, Jeon UB, et al. Celiac axis and common hepatic artery variations in 5002 patients: systematic analysis with spiral CT and DSA. Radiology. 2010;255(1):278–88.

    Article  PubMed  Google Scholar 

  18. Woods MS, Traverso LW. Sparing a replaced common hepatic artery during pancreaticoduodenectomy. Am Surg. 1993;59(11):719–21.

    CAS  PubMed  Google Scholar 

  19. Volpe CM, Peterson S, Hoover EL, Doerr RJ. Justification for visceral angiography prior to pancreaticoduodenectomy. Am Surg. 1998;64(8):758–61.

    CAS  PubMed  Google Scholar 

  20. Furukawa H, Shimada K, Iwata R, Moriyama N. A replaced common hepatic artery running through the pancreatic parenchyma. Surgery. 2000;127(6):711–2.

    Article  CAS  PubMed  Google Scholar 

  21. Sakorafas GH, Sarr MG, Peros G. Celiac Artery Stenosis: an underappreciated and unpleasant surprise in patients undergoing pancreaticoduodenectomy. J Am Coll Surg. 2008;206(2):349–56.

    Article  PubMed  Google Scholar 

  22. Park CM, Chung JW, Kim HB, Shin SJ, Park JH. Celiac axis stenosis: incidence and etiologies in asymptomatic individuals. Korean J Radiol. 2001;2(1):8–13.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Berney T, Pretre R, Chassot G, Morel P. The role of revascularization in celiac occlusion and pancreatoduodenectomy. Am J Surg. 1998;176(4):352–6.

    Article  CAS  PubMed  Google Scholar 

  24. Corinne Winston JT. Computer tomography of the liver, biliary tract, and pancreas. In: Jarnagin WR, editor. Blumgart’s surgery of the liver, pancreas, and biliary tract. 5th ed. Philadelphia: Elsevier Saunders; 2012.

    Google Scholar 

  25. Sahani D, Saini S, Pena C, Nichols S, Prasad SR, Hahn PF, et al. Using multidetector CT for preoperative vascular evaluation of liver neoplasms: technique and results. AJR Am J Roentgenol. 2002;179(1):53–9.

    Article  PubMed  Google Scholar 

  26. Takahashi S, Murakami T, Takamura M, Kim T, Hori M, Narumi Y, et al. Multi-detector row helical CT angiography of hepatic vessels: depiction with dual-arterial phase acquisition during single breath hold. Radiology. 2002;222(1):81–8.

    Article  PubMed  Google Scholar 

  27. Winston CB, Lee NA, Jarnagin WR, Teitcher J, DeMatteo RP, Fong Y, et al. CT angiography for delineation of celiac and superior mesenteric artery variants in patients undergoing hepatobiliary and pancreatic surgery. AJR Am J Roentgenol. 2007;189(1):W13–9.

    Article  PubMed  Google Scholar 

  28. Tamm EP, Balachandran A, Bhosale PR, Katz MH, Fleming JB, Lee JH, et al. Imaging of pancreatic adenocarcinoma: update on staging/resectability. Radiol Clin North Am. 2012;50(3):407–28.

    Article  PubMed  Google Scholar 

  29. Schwartz LH. Magnetic resonance imaging of the liver, biliary tract, and pancreas. In: Jarnagin WR, editor. Blumgart’s surgery of the liver, pancreas and biliary tract. 5th ed. Philadelphia: Elsevier Saunders; 2012.

    Google Scholar 

  30. Varadarajulu S, Eloubeidi MA. The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer. Surg Clin North Am. 2010;90(2):251–63.

    Article  PubMed  Google Scholar 

  31. Winston CB, Lee NA, Jarnagin WR, Teitcher J, DeMatteo RP, Fong Y, et al. CT angiography for delineation of celiac and superior mesenteric artery variants in patients undergoing hepatobiliary and pancreatic surgery. AJR Am J Roentgenol. 2007;189(1):W13–9.

    Article  PubMed  Google Scholar 

  32. Graham RR, Cannell CD. Accidental ligation of the hepatic artery. Br J Surg. 1933;20:566.

    Article  Google Scholar 

  33. Brittain RS, Marchioro TL, Hermann G, Waddell WR, Starzl TE. Accidental hepatic artery ligation in humans. Am J Surg. 1964;107:822–32.

    Google Scholar 

  34. Plengvanit U, Chearanai O, Sindhvananda K, Dambrongsak D, Tuchinda S, Viranuvatti V. Collateral arterial blood supply of the liver after hepatic artery ligation, angiographic study of twenty patients. Ann Surg. 1972;175(1):105–10.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  35. Mays ET, Wheeler CS. Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med. 1974;290(18):993–6.

    Article  CAS  PubMed  Google Scholar 

  36. Lewis FR, Lim RC Jr, Blaisdell FW. Hepatic artery ligation: adjunct in the management of massive hemorrhage from the liver. J Trauma. 1974;14(9):743–55.

    Article  CAS  PubMed  Google Scholar 

  37. Flint LM, Mays ET, Aaron WS, Fulton RL, Polk HC. Selectivity in the management of hepatic trauma. Ann Surg. 1977;185(6):613–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  38. McDermott WV Jr, Hensle TW. Metastatic carcinoid to the liver treated by hepatic dearterialization. Ann Surg. 1974;180(3):305–8.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Lee YT. Liver function tests after ligation of hepatic artery. J Surg Oncol. 1978;10(4):305–20.

    Article  CAS  PubMed  Google Scholar 

  40. Allen PJ, Stojadinovic A, Ben-Porat L, Gonen M, Kooby D, Blumgart L, et al. The management of variant arterial anatomy during hepatic arterial infusion pump placement. Ann Surg Oncol. 2002;9(9):875–80.

    Article  PubMed  Google Scholar 

  41. Nancy E. Kemeny ASE. Regional chemotherapy for liver tumors. In: Jarnagin WR, editor. Blumgart’s surgery of the liver, pancreas and biliary tract. 5th ed. Philadelphia: Elsevier-Saunders; 2012.

    Google Scholar 

  42. Makary MA, Fishman EK, Cameron JL. Resection of the celiac axis for invasive pancreatic cancer. J Gastrointest Surg. 2005;9(4):503–7.

    Article  PubMed  Google Scholar 

  43. Smoot RL, Donohue JH. Modified Appleby procedure for resection of tumors of the pancreatic body and tail with celiac axis involvement. J Gastrointest Surg. 2012;16(11):2167–9.

    Article  PubMed  Google Scholar 

  44. Doppman JL, Girton M, Vermess M. The risk of hepatic artery embolization in the presence of obstructive jaundice. Radiology. 1982;143(1):37–43.

    Article  CAS  PubMed  Google Scholar 

  45. Soares AF, Castro e Silva Junior O, Ceneviva R, Roselino JE, Zucoloto S. Biochemical and morphological changes in the liver after hepatic artery ligation in the presence or absence of extrahepatic cholestasis. Int J Exp Pathol. 1993;74(4):367–70.

    PubMed Central  CAS  PubMed  Google Scholar 

  46. Nath B, Szabo G. Hypoxia and hypoxia inducible factors: diverse roles in liver diseases. Hepatology. 2012;55(2):622–33.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  47. Alves A, Farges O, Nicolet J, Watrin T, Sauvanet A, Belghiti J. Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg. 2003;238(1):93–6.

    PubMed Central  PubMed  Google Scholar 

  48. Traverso LW, Freeny PC. Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula. Am Surg. 1989;55(7):421–6.

    CAS  PubMed  Google Scholar 

  49. Kochhar G, Parungao JM, Hanouneh IA, Parsi MA. Biliary complications following liver transplantation. World J Gastroenterol. 2013;19(19):2841–6.

    PubMed Central  PubMed  Google Scholar 

  50. Mezhir JJ, Brennan MF, Baser RE, D’Angelica MI, Fong Y, DeMatteo RP, et al. A matched case-control study of preoperative biliary drainage in patients with pancreatic adenocarcinoma: routine drainage is not justified. J Gastrointest Surg. 2009;13(12):2163–9.

    Article  PubMed  Google Scholar 

  51. van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362(2):129–37.

    Article  Google Scholar 

  52. Tol JA, Busch OR, van der Gaag NA, van Gulik TM, Gouma DJ. The quandary of preresection biliary drainage for pancreatic cancer. Cancer J. 2012;18(6):550–4.

    Article  PubMed  Google Scholar 

  53. Miura T, Hakamada K, Ohata T, Narumi S, Toyoki Y, Nara M, et al. Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization: a case report. World J Gastroenterol. 2008;14(22):3587–90.

    Article  PubMed Central  PubMed  Google Scholar 

  54. Hasegawa K, Imamura H, Akahane M, Miura Y, Takayama T, Ohtomo K, et al. Endovascular stenting for celiac axis stenosis before pancreaticoduodenectomy. Surgery. 2003;133(4):440–2.

    Article  PubMed  Google Scholar 

  55. Halazun KJ, Kotru A, Menon KV, Patel J, Prasad KR. Stenting of coeliac axis stenosis facilitates pancreatectomy. Eur J Surg Oncol. 2006;32(7):811–2.

    Article  CAS  PubMed  Google Scholar 

  56. Farma JM, Hoffman JP. Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy. Am J Surg. 2007;193(3):341–4. Discussion 4.

    Article  PubMed  Google Scholar 

  57. Lochan R, White SA. Pre-operative endovascular stenting of the coeliac trunk. Ann R Coll Surg Engl. 2008;90(2):173–4.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  58. Sharafuddin MJ, Olson CH, Sun S, Kresowik TF, Corson JD. Endovascular treatment of celiac and mesenteric arteries stenoses: applications and results. J Vasc Surg. 2003;38(4):692–8.

    Article  PubMed  Google Scholar 

  59. van Wanroij JL, van Petersen AS, Huisman AB, Mensink PB, Gerrits DG, Kolkman JJ, et al. Endovascular treatment of chronic splanchnic syndrome. Eur J Vasc Endovasc Surg. 2004;28(2):193–200.

    Article  CAS  PubMed  Google Scholar 

  60. Cloyd JM, Chandra V, Louie JD, Rao S, Visser BC. Preoperative embolization of replaced right hepatic artery prior to pancreaticoduodenectomy. J Surg Oncol. 2012;106(4):509–12.

    Article  PubMed  Google Scholar 

  61. Turrini O, Wiebke EA, Delpero JR, Viret F, Lillemoe KD, Schmidt CM. Preservation of replaced or accessory right hepatic artery during pancreaticoduodenectomy for adenocarcinoma: impact on margin status and survival. J Gastrointest Surg. 2010;14(11):1813–9.

    Article  PubMed  Google Scholar 

  62. Eshuis WJ, Olde Loohuis KM, Busch ORC, van Gulik TM, Gouma DJ. Influence of aberrant right hepatic artery on perioperative course and longterm survival after pancreatoduodenectomy. HPB (Oxford). 2011;13(3):161–7.

    Google Scholar 

  63. Cikrit DF, Dalsing MC, Sawchuk AP, Lalka SG, Harl MJ, Goulet RJ, et al. Vascular injuries during pancreatobiliary surgery. Am Surg. 1993;59(10):692–6. Discussion 7.

    CAS  PubMed  Google Scholar 

  64. Lygidakis NJ. Regional vascular resection for pancreatic head carcinoma. Hepatogastroenterology. 1996;43(11):1327–33.

    CAS  PubMed  Google Scholar 

  65. Fischer CP, Rosenberg W, Bridget F, Bass B. Gastroduodenal artery used for arterial reconstruction during the Whipple operation. Hepatogastroenterology. 2007;54(80):2228–9.

    PubMed  Google Scholar 

  66. Kusano T, Tamai O, Miyazato H, Isa T, Shiraishi M, Muto Y. Vascular reconstruction of the hepatic artery using the gastroepiploic artery: a case report. Hepatogastroenterology. 1999;46(28):2278–80.

    CAS  PubMed  Google Scholar 

  67. Sarmiento JM, Panneton JM, Nagorney DM. Reconstruction of the hepatic artery using the gastroduodenal artery. Am J Surg. 2003;185(4):386–7.

    Article  PubMed  Google Scholar 

  68. Faulds J, Johner A, Klass D, Buczkowski A, Scudamore CH. Hepatic artery transection reconstructed with splenic artery transposition graft. Perspect Vasc Surg Endovasc Ther. 2012;24(2):87–9.

    Article  PubMed  Google Scholar 

  69. Ohwada S, Ogawa T, Ohya T, Kawashima Y, Nakamura S, Satoh Y, et al. Gonadal vein graft for hepatic artery reconstruction. Hepatogastroenterology. 1999;46(27):1823–6.

    CAS  PubMed  Google Scholar 

  70. Pessaux P, Varma D, Arnaud JP. Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg. 2006;10(4):607–11.

    Article  PubMed  Google Scholar 

  71. Dumitrascu T, David L, Popescu I. Posterior versus standard approach in pancreatoduodenectomy: a case-match study. Langenbecks Arch Surg. 2010;395(6):677–84.

    Article  PubMed Central  PubMed  Google Scholar 

  72. Pessaux P, Marzano E, Rosso E. A plea for the artery-first dissection during pancreaticoduodenectomy. J Am Coll Surg. 2010;211(1):142–3.

    Article  PubMed  Google Scholar 

  73. Weitz J, Rahbari N, Koch M, Buchler MW. The “artery first” approach for resection of pancreatic head cancer. J Am Coll Surg. 2010;210(2):e1–4.

    Article  PubMed  Google Scholar 

  74. Lupascu C, Moldovanu R, Andronic D, Ursulescu C, Vasiluta C, Raileanu G, et al. Posterior approach pancreaticoduodenectomy: best option for hepatic artery anatomical variants. Hepatogastroenterology. 2011;58(112):2112–4.

    PubMed  Google Scholar 

  75. Sakamoto Y, Sano T, Shimada K, Kosuge T, Kimata Y, Sakuraba M, et al. Clinical significance of reconstruction of the right hepatic artery for biliary malignancy. Langenbecks Arch Surg. 2006;391(3):203–8.

    Article  PubMed  Google Scholar 

  76. Allendorf JD, Bellemare S. Reconstruction of the replaced right hepatic artery at the time of pancreaticoduodenectomy. J Gastrointest Surg. 2009;13(3):555–7.

    Article  PubMed  Google Scholar 

  77. Amano H, Miura F, Toyota N, Wada K, Katoh K, Hayano K, et al. Pancreatectomy with reconstruction of the right and left hepatic arteries for locally advanced pancreatic cancer. J Hepatobiliary Pancreat Surg. 2009;16(6):777–80.

    Article  PubMed  Google Scholar 

  78. Yamamoto S, Kubota K, Rokkaku K, Nemoto T, Sakuma A. Disposal of replaced common hepatic artery coursing within the pancreas during pancreatoduodenectomy: report of a case. Surg Today. 2005;35(11):984–7.

    Article  PubMed  Google Scholar 

  79. Nagai H, Ohki J, Kondo Y, Yasuda T, Kasahara K, Kanazawa K. Pancreatoduodenectomy with preservation of the pylorus and gastroduodenal artery. Ann Surg. 1996;223(2):194–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  80. Yasuda Y, Larsen PN, Ishibashi T, Yamashita K, Toei H. Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery. HPB (Oxford). 2010;12(2):147–52.

    Article  Google Scholar 

  81. de Santibanes E, Ardiles V, Alvarez FA, Pekolj J, Brandi C, Beskow A. Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy. HPB (Oxford). 2012;14(1):67–70.

    Google Scholar 

  82. Blumgart LH, Hann LE. Blumgart's surgery of the liver, pancreas and biliary tract. Vol. 1. New York: Springer; 2012.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

    Vinod P. Balachandran MD

  2. Department of Surgery, Hepatopancreatobiliary Division, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, 10065, New York, NY, USA

    Michael I. D’Angelica MD, FACS

Authors
  1. Vinod P. Balachandran MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael I. D’Angelica MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael I. D’Angelica MD, FACS .

Editor information

Editors and Affiliations

  1. Division of Surgical Oncology, Johns Hopkins Hospital, Baltimore, Maryland, USA

    Timothy M. Pawlik

  2. Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA

    Shishir K. Maithel

  3. Professor of Surgery, Division of Surgical Oncology, University of Miami, Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida, USA

    Nipun B. Merchant

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer Science+Business Media New York

About this chapter

Cite this chapter

Balachandran, V., D’Angelica, M. (2015). Intraoperative Injury to Hepatic Arterial Structures. In: Pawlik, T., Maithel, S., Merchant, N. (eds) Gastrointestinal Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2223-9_21

Download citation

  • DOI: https://doi.org/10.1007/978-1-4939-2223-9_21

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-2222-2

  • Online ISBN: 978-1-4939-2223-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation