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Anatomical Variations of the Cystic Artery and Laparoscopic Cholecystectomy: A Persisting Surgical Challenge
Miltiadis Perdikakis1, Artemis Liapi2, Andreas Kiriakopoulos1
15th Department of Surgery, Evgenidion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, GRC.
Insights
A rare anatomical variation in laparoscopic cholecystectomy involved the cystic artery originating from the middle hepatic artery. This case highlights the importance of recognizing arterial variations for surgical safety.
Area of Science:
- Surgical Anatomy
- Hepatobiliary Surgery
- Minimally Invasive Surgery
Background:
- Elective laparoscopic cholecystectomy is a common procedure but can be complicated by anatomical variations.
- Variations in cystic artery and cystic bile duct anatomy pose challenges during dissection of Calot's triangle.
Observation:
- During a laparoscopic cholecystectomy for symptomatic cholelithiasis, an unusual cystic artery origin was identified.
- The cystic artery arose from the middle hepatic artery, not the typical right hepatic artery.
Findings:
- This case presented a rare arterial variation where the cystic artery originated from the middle hepatic artery, which itself had a rare origin from the anterior branch of the right hepatic artery.
- Retrograde dissection facilitated visualization and protection of the anomalous middle hepatic artery.
Implications:
- Accurate intraoperative recognition of arterial variations is crucial to prevent inadvertent ligation of vital structures.
- Enhanced anatomical knowledge and techniques like retrograde dissection improve safety in laparoscopic cholecystectomy.
- Adherence to critical view of safety dissection principles is paramount in managing anatomical complexities.
Abstract:
Although elective laparoscopic cholecystectomy is a common surgical procedure, it can become challenging due to multiple variants of the anatomy of both cystic artery and cystic bile duct. A 52-year-old male with a history of symptomatic cholelithiasis underwent elective laparoscopic cholecystectomy. During preparation of the Calot's triangle in order to achieve the "critical view of safety", an uncommon variation of the arterial anatomy was detected. The cystic artery was found to be originating from a robust middle hepatic artery instead of the right hepatic artery. The retrograde manner of cholecystectomy helped the visualization and protection of the middle hepatic artery. This anatomic finding was confirmed per CT done postoperatively. This case constitutes a rare arterial variation, in which the cystic artery arises from the middle hepatic artery, the artery that supplies the hepatic segment IV, which itself constituted a rare variation, since it arose from the anterior branch of the right hepatic artery. This artery could be falsely ligated instead of the real cystic artery. Certain techniques can be used to enhance the surgeon's ability to distinguish and safely ligate the proper entities. Anatomic knowledge of the possible variations of arterial and bile vessels is crucial for intraoperative recognition. Dissection of the Calot's triangle and reassurance of the "critical view of safety" are mandatory dissection techniques during laparoscopic cholecystectomy. Additionally, the retrograde manner of cholecystectomy can be of significant help in case of unclear anatomy in order to avoid ligation of uncertain entities during dissection.
