Masuya Ryuta, Miyoshi Kina, Nakame Kazuhiko, Nanashima Atsushi, Ieiri Satoshi
Division of the Gastrointestinal, Endocrine and Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
Department of Pediatric Surgery, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan.
Int J Surg Case Rep. 2021 Sep;86:106300. doi: 10.1016/j.ijscr.2021.106300. Epub 2021 Aug 11.
The right hepatic artery crossing the ventral side of the common hepatic duct is a relatively frequent abnormality. This aberrant right hepatic artery not only interferes with dissection of the common bile duct and hepaticojejunostomy for choledochal cyst but can also cause postoperative anastomotic stenosis.
A 14-year-old patient presented with upper abdominal pain and was diagnosed with a choledochal cyst (Type IVA in Todani Classification) and pancreaticobiliary maljunction. Abdominal enhanced computed tomography showed aberrant right hepatic artery located at the ventral side of the common hepatic duct. Laparoscopic choledochal cyst resection and hepaticojejunostomy were planned. Intraoperative findings also showed the aberrant right hepatic artery crossing the common hepatic duct ventrally as detected on preoperative computed tomography. Laparoscopic dorsal side repositioning of the aberrant right hepatic artery was performed because it appeared to compress the common hepatic duct and risked causing postoperative anastomotic stenosis. We performed laparoscopic hepaticojejunostomy by replacing the aberrant right hepatic artery dorsally to facilitate suturing and prevent postoperative anastomotic stenosis. The postoperative course was uneventful, with no findings suggestive of anastomotic stenosis.
The abnormality of the right hepatic artery is reported to be a primary cause of anastomotic stenosis after hepaticojejunostomy. Once anastomotic stenosis or stricture develops, it is often difficult to treat. The prevention of the stenosis is important.
In choledochal cyst with aberrant right hepatic artery, dorsal repositioning is effective for preventing postoperative anastomotic stenosis and cholestasis.
右肝动脉从肝总管腹侧穿过是一种相对常见的异常情况。这种异常的右肝动脉不仅会干扰胆总管的解剖以及胆总管囊肿的肝管空肠吻合术，还可能导致术后吻合口狭窄。
一名14岁患者因上腹部疼痛就诊，被诊断为胆总管囊肿（Todani分类中的IVA型）和胰胆管合流异常。腹部增强计算机断层扫描显示异常右肝动脉位于肝总管腹侧。计划进行腹腔镜胆总管囊肿切除术和肝管空肠吻合术。术中所见也显示异常右肝动脉如术前计算机断层扫描所检测的那样从肝总管腹侧穿过。由于异常右肝动脉似乎压迫肝总管并有导致术后吻合口狭窄的风险，因此对其进行了腹腔镜下背侧重新定位。我们通过将异常右肝动脉置于背侧来进行腹腔镜肝管空肠吻合术，以利于缝合并防止术后吻合口狭窄。术后过程顺利，未发现提示吻合口狭窄的情况。
据报道，右肝动脉异常是肝管空肠吻合术后吻合口狭窄的主要原因。一旦发生吻合口狭窄或狭窄，往往难以治疗。预防狭窄很重要。
在伴有异常右肝动脉的胆总管囊肿中，背侧重新定位对于预防术后吻合口狭窄和胆汁淤积有效。
