Justification for visceral angiography prior to pancreaticoduodenectomy.

The hepatic arterial anatomy is aberrant in almost 50 per cent of all individuals. The most common anomalies include the right hepatic artery arising from the superior mesenteric artery (25%) and the left hepatic artery arising from the left gastric artery (25%). Anomalies of the common hepatic artery, usually a branch of the celiac artery, are rare. A replaced common hepatic artery originating from the superior mesenteric artery occurs in 2.5% of the entire population. Injury to hepatic blood supply is more common in the presence of aberrant arterial anatomy. Knowledge of aberrant arterial anatomy in patients about to undergo pancreaticoduodenectomy can lead to measures to preserve the vessels, and avoid fatal hepatic injury. We present a patient with a replaced common hepatic artery originating from the superior mesenteric artery successfully treated with a standard pancreaticoduodenectomy for pancreatic adenocarcinoma. The anomalous vessel was identified on visceral angiography, performed as part of the initial preoperative evaluation. At the time of laparotomy, the artery followed a course atypical for replaced hepatic arteries, lying medial to the common bile duct, and closely mimicking the gastroduodenal artery that would normally be divided during a Whipple procedure. This case emphasizes the importance of preoperative visceral angiography and the margin of safety it can provide when that knowledge is used in the operative strategy. Visceral angiography should be considered routine before pancreaticoduodenectomy, particularly in surgical residency training programs.