Intestinal malrotation and replaced common hepatic artery during duodenopancreatectomy: a case report

Intestinal malrotation is a well-known anomaly in the normal rotation process of the midgut during embryogenesis. Multiple forms are described, resulting in various positional configurations of the small bowel and colon. Replaced common hepatic artery is a rare but not anecdotic variant of the standard hepatic vascularization, associated with surgical implications. Our aim is to explain the impact of their simultaneous presence during this procedure and the difficulty in identifying them preoperatively, despite imaging.

These two abnormalities were simultaneously observed in our patient who underwent a duodenopancreatectomy for an adenocarcinoma of the head of the pancreas.

In our case, intestinal malrotation and replaced common hepatic artery were discovered preoperatively. Malrotation made the dissection and kocherization more easier. Replaced common hepatic artery required a carefully skeletonized dissection, first posteriorly And then into the pancreatic parenchyma, before being partially resected and then primarily anastomosed.

Preoperative imaging is crucial to define the lesion resectability, the proximity with the tumor, and also to identify these vascular anomalies and their relation with the pancreas parenchyma, in order to adjust the surgical strategy and preserve them, avoiding many complications (massive hepatic necrosis, chronic biliary ischemia, bleedings, etc.). In this context, angioscanner with 3D reconstruction is considered as a gold standard and should always be performed before a duodenopancreatectomy.