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Cholecystectomy
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
The cystic artery usually traverses Calot's triangle arising from an anterior right hepatic artery. It can be ligated and divided safely only if it can be shown to be supplying the gallbladder (and nothing else). There are many variations of arterial anatomy which can confuse and render the right hepatic artery at risk. One such is the caterpillar hump (of Moynihan) configuration, making it unduly prominent in Calot's triangle (Figure 54.5). Dissection of the cystic duct down to the junction with CBD is relatively straightforward being in continuity with Hartmann's pouch. Nonetheless, variations include a low insertion near the duodenum or even within the pancreas. Where there is doubt, a cholangiogram is indicated. Both cystic duct and artery can be divided and ligated with absorbable material.
Biliary obstruction and leaks
Published in David Westaby, Martin Lombard, Therapeutic Gastrointestinal Endoscopy A problem-oriented approach, 2019
The bile duct, and particularly the subhilar hepatic duct, seems to be especially susceptible to ischaemic bile duct injury. The blood supply is derived from the right hepatic artery and the hepaticoduodenal artery, fine branches of which run along the bile duct fascia and can be easily injured. Resection or ligation of the hepatic artery can result in total bile duct ischaemia, and this may cause a very tight fibrotic stricture (Figs 10.4–10.7).
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
The gallbladder is supplied by the cystic artery, usually a branch of the right hepatic artery. It runs across the triangle formed by the liver, common hepatic duct, and cystic duct to reach the gallbladder (Calot’s triangle). Calot’s triangle reliably contains the cystic artery, the cystic lymph node (of Lund), connective tissue, and lymphatics. It is important to dissect out this triangle at laparoscopic cholecystectomy in order to successfully identify and ligate the cystic artery prior to removal of the gallbladder.
Anatomic Variation of the Cystic Artery: New Findings and Potential Implications
Published in Journal of Investigative Surgery, 2021
Li Li, Qiang Li, Mingguo Xie, Wenwei Zuo, Bin Song
Awareness of variant anatomy, such as a zero angle between the cystic artery and right hepatic artery injury, could also be useful in preventing right hepatic artery injury. In some reports, authors had described right hepatic artery or its branches injury was present in 7% (5/71) of cadavers that had undergone cholecystectomy and had no abnormality of the liver or bile ducts [36]. Consequences of right hepatic artery injury include hemorrhage, right lobe atrophy, hemophilia, infection, and hepatic ischemia. Some of these complications have necessitated hepatectomy or even hepatic transplantation, particularly if accompanied by biliary injury [4,14,21,22,16]. A classification of laparoscopic biliary injuries mechanisms exists (the Stewart-Way classification), which groups injuries based on anatomic pattern and mechanism of laparoscopic injury [37]. Having the right hepatic artery mistaken for the cystic artery is one of causes (Stewart-Way class IV) [14,36]. It is conceivable that a zero-angle cystic artery is more likely to be mistakenly identified as the right hepatic artery, because the straight-line course of the cystic artery and right hepatic artery does not reveal an obvious boundary during cystic artery dissection; and boundary detection is more difficult due to the lack of depth perception and inherent visual limitations of laparoscopic procedures [4]. Although it was unclear how often right hepatic artery injury were associated with such variant anatomy, it is conceivable that awareness such variant anatomy may decrease the potential risk of accidental the right hepatic artery injury during LC.
A comparison between the mechanical properties of the hepatic round ligament and the portal vein: a clinical implication on surgical reconstruction of the portal and superior mesenteric veins
Published in Computer Methods in Biomechanics and Biomedical Engineering, 2020
Wentao Zhu, Rongqiang Song, Xuefeng Cao, Lei Zhou, Qiang Wei, Haibin Ji, Rongzhan Fu
Hepatic round ligament (HRL), also known as ligamentum teres, is the remnant of the embryonic umbilical vein, which degenerates after birth (Emre et al. 1993). It is located between the umbilicus and the left branch of the portal vein (PV), connecting the left hepatic vein or the inferior vena cava via the venous ligament. Anatomically, it can be divided into intraperitoneal and extraperitoneal segments. Structurally, it is organized into the inner, middle and outer layers and still retains the structural features of the blood vessel wall that is composed of collagen and elastic fibers, as well as smooth muscles. A distinct elastic muscle band enriched with smooth muscle, elastic and collagen fibers exist between the inner and middle layer. Blood supply to the HRL is sufficiently provided by the right hepatic artery and the umbilical vein. Clinically, narrowed or obstructed HRL can be widened to reconnect with the PV (Ikegami et al. 2008).
Combined trans-arterial embolisation and microwave ablation for the treatment of large unresectable hepatic metastases (>3 cm in maximal diameter)
Published in International Journal of Hyperthermia, 2020
Eliodoro Faiella, Domiziana Santucci, Caterina Bernetti, Emiliano Schena, Giuseppina Pacella, Bruno Beomonte Zobel, Rosario Francesco Grasso
The percentage increase in terms of diameter of the treated tumors with respect to stand-alone MWA procedures (as per previous ex-vivo experiments conducted with the same MWA equipment in the same working conditions) was higher when delivering a higher MW power for a shorter time. Larger tumors yielded better results (i.e., exhibited a higher percentile increase in ablation volume with respect to stand-alone MWA treatments), especially those localized in the lower hepatic segments. These results may be explained by considering the different vascular distributions between the upper and lower hepatic segments. In particular, the blood is supplied to the lower segments mainly by the right hepatic artery, while the upper segments are fed by the right and left hepatic arteries and phrenic arteries. This may result in a less clearly defined vascularization for tumors located in the upper segments, which in turn may reduce the local efficacy of TAE procedures.