Aberrant right hepatic arterial anatomy and pancreaticoduodenectomy: Recognition, prevalence and management

Background: Aberrant arterial anatomy is a common finding during foregut surgery. Anomalies to the right hepatic lobe are especially relevant during pancreaticoduodenectomy (PD) and their recognition serves to protect the blood supply to the liver and bile ducts. We report our experience with aberrant right hepatic arterial anatomy (ARHAA) found during PD. Methods: All patients who underwent PD between February 2003 and June 2007 were retrospectively reviewed and those with ARHAA were identified. Preoperative imaging studies were assessed by one radiologist, graded according to the presence of ARHAA and compared with the original interpretations. Results: We found ARHAA in 31 of 191 patients (16.2%). Operative management included dissection and preservation in 24, transection and reconstruction in four, and transection and primary anastomosis in three patients. Reconstruction of ARHAA was carried out through interposition grafts in two patients and implantation into the gastroduodenal stump in two patients. No cases of arterial thrombosis, liver infarction, abscess formation or biliary fistula were demonstrated in the immediate postoperative period. Review of preoperative imaging interpretations found that only nine of 23 reports indicated the presence of ARHAA; however, the retrospective review of the images found that ARHAA was readily apparent in 24 patients. Discussion: Recognition of aberrant vasculature to the liver before PD is important. Preoperative imaging studies will often be adequate to identify these anomalies, but interpreting radiologists may not be aware of its clinical significance. Surgeons performing PD must be adept at managing ARHAA safely.