[Pancreatoduodenectomy with reconstruction of an aberrant right hepatic artery].

Hepatic arterial vascularization presents great anatomic variability. The vascular configuration described as normal is found in only 55%–75.5% of cases, which means that a large percentage of patients present an anatomic variation. Amongst them, the most frequent variation is the right hepatic artery (RHA), branch of the superior mesenteric artery (SMA). This variation can involve a single right hepatic artery, called ‘‘aberrant’’, that originates in the SMA; instead, there may be 2 coexisting right hepatic arteries (one branch originating in the SMA, called ‘‘accessory’’, and another of the proper hepatic artery). The importance of the presence of a variant hepatic artery in pancreatic surgery has been commented in several publications. An RHA that irrigates in the SMA has a close relationship with the head of the pancreas since its course is adjacent and occasionally passes through its parenchyma. Due to this disposition, it is susceptible to being infiltrated by tumors of the pancreatic head. Furthermore, the absence of collateral vascularization and the inadvertent sectioning of an RHA branch of the SMA during a pancreaticoduodenectomy (PD) can lead to ischemia and necrosis of the right liver lobe. Finally, once the gastroduodenal artery is dissected, the RHA branch of the SMA becomes the main source of vascularization of the distal common bile duct. We present a case of distal cholangiocarcinoma with infiltration of an aberrant RHA (ARHA) that was satisfactorily resolved with arterial reconstruction without the use of vascular stents. The patient is a 54-year-old woman who had been studied for obstructive jaundice and treated with percutaneous transhepatic cholangiography. CT angiography demonstrated a tumor that was obstructing the distal common bile duct and detected the infiltration of an ARHA. No liver metastases or infiltration of the SMA were observed. These findings indicated the need for a PD (Figs. 1 and 2). To identify the RHA branch of the SMA, we carefully dissected the hepatoduodenal ligament after having palpated the free edge of the ligament, which confirmed the presence of arterial pulse. Using an extended Kocher maneuver, we observed the SMA at its origin and confirmed the absence of tumor infiltration. In the same manner, we carefully dissected the common bile duct to decrease the risk of inadvertently ligating the RHA branch of the SMA, which in this area is located postero-lateral to the common hepatic duct. As part of the lymph node dissection, skeletization of the portal vein and common hepatic artery was performed. ARHA was confirmed as there was no right hepatic artery stemming from the proper hepatic artery. In cases of infiltration by the tumor mass, as seen in our patient, or in those with an intrapancreatic pathway, the artery should be sacrificed with the PD surgical specimen and later reconstructed. We used vascular micro-bulldog clamps on the common hepatic artery, proper hepatic artery and the ARHA to dissect the gastroduodenal artery (GDA), while preserving as much of its length as possible. In our case, we obtained 15 mm up until the bifurcation of the superior pancreaticoduodenal arteries. Afterwards, we dissected the isthmus and confirmed the inclusion of the ARHA branch of the SMA in the tumor mass.