Anatomy and variations of the celiac trunk/Anatomia y variaciones del tronco celiaco.
KEY WORDS: Anatomy; Celiac trunk; Anatomical variations.
RESUMEN: El objetivo de este estudio fue analizar la anatomia del tronco celiaco a traves de sus diametro, longitud, origen y variacion de sus ramos. Fueron disecados 69 cadaveres fijados en formalina al 10% en los Laboratorios Anatomia de la Universidad Federal de Sao Paulo (UNIFESP/EPM), Universidad Lusiadas de Santos y Universidad Santo Amaro (UNISA), Brasil y 20 cadaveres del Servicio de Verificacion de Obitos de la Universidad Sao Paulo (USP) y de la Universidad Federal de Sao Paulo (UNIFESP/EPM), Brasil. Las disecciones de la region del tronco celiaco fueron realizadas despues de hacerlo con la cavidad peritoneal. Los resultados obtenidos permitieron llegar a las siguientes conclusiones: 1) La longitud media del tronco celiaco hasta su primera rama, la arteria gastrica izquierda y/o esplenica en 81 cadaveres fue de 1,23 cm en el sexo masculino y 1,18 cm en el femenino. Verificamos como primer ramo del tronco celiaco, la arteria gastrica izquierda en 55 (67,90%), arteria esplenica en dos (2.47%), ambas en seis (7,41%), y en 18 (22,22%), las tres arterias trifurcandose en la misma altura formando el triple de Haller. 2) La medida de la longitud del tronco celiaco hasta su ultimo ramo, la arteria hepatica comun y/o esplenica en 68 cadaveres, tuvo una longitud media de 1,74 cm en el sexo masculino y 1,74 cm en el femenino. Verificamos como ultimo ramo del tronco celiaco, la arteria hepatica comun en 13 (19,12%), la arteria esplenica en cuatro (5.88%), ambas en 33 (48,53%) y en 18 (22,22%), las tres arterias trifurcandose en la misma altura. 3) La medida del diametro del tronco celiaco en 77 cadaveres tuvo una mediana de 0.65 cm en el sexo masculino y 0,67 cm en el femenino. 4) La medida de la distancia entre el tronco celiaco y la arteria mesenterica superior en 76 cadaveres, tuvo una mediana de 0,72 cm en el sexo masculino y 0,74 cm en el femenino. 5) El tronco celiaco emitio las arterias gastrica izquierda, esplenica y hepatica en 73 (82,02%) de los 89 cadaveres. En los otros 16 (17,98%) observamos variaciones en cuanto al numero de arterias emitidas y a la disposicion de estas en el tronco celiaco. Este emitio, ademas de sus tres arterias, una arteria gastroduodenal en seis (6,74%), un tronco gastroduodenocolico en uno (1,12%), una arteria hepatica accesoria en dos (2,25%). Tambien verificamos en tres (3,37%) un tronco gastroesplenico, en dos (2,5%) un tronco hepatoesplenico, en uno (1,12%) la arteria hepatica comun como unico ramo y en uno (1,12%) la ausencia del tronco celiaco.
PALABRAS CLAVE: Anatomia; Trono celiaco; Variaciones anatomicas.
The celiac trunk is the first visceral collateral branch of the abdominal part of aorta, originating at its anterior contour just below the aortic hiatus of diaphragm. It has been referred as a short and calibrous trunk, ranging from 5 to 40mm in length and a mean of 10 to 25 mm (Rio Branco, 1912); 1 to 2 cm (Tandler, 1929); up to 12 mm (Orts-Llorca, 1944); 8 to 40 mm (Michels, 1951); 10 mm (Fumagalli & Cavallotti, 1983); 10 to 15 mm (Latarjet & Ruiz-Liard, 1989) and diameter ranging from 4 to 10 mm (Rio Branco); 3 to 12mm (Michels, 1951); 10 to 12 mm (Pignataro, 1969); 7 mm (Fumagalli & Cavallotti); 6 mm on average (Latarjet & Ruiz-Liard). It is situated between the T12-L1 vertebrae (Lipshutz, 1917; George, 1934; Anson & McVay, 1936); Cauldwell & Anson, 1943; Riva, 1967; Warter et al., 1970; Stanley & Fry, 1971; Furnemont, 1974; Warter et al., 1976) with no direct relationship with fibrous ring of the aortic hiatus, whose free anterior margin usually crosses the aorta just above the celiac trunk at the level of the T11-T12 vertebrae (Reuter, 1971; Warter et al.) or the T 12-L1 vertebrae (Stoney & Wylie, 1966). The most frequent origin of the celiac trunk is at the third superior level of the L1 vertebra (George; Anson & McVay; Cauldwell & Anson) and 20% of the cases they originated higher at the T12 vertebra above the arcuate ligament (George; Cauldwell & Anson).
After a trajectory of 1.0 cm or 1.5 cm and displaying in front and above the superior margin of the pancreas, the celiac trunk is divided into two branches: one right, the hepatic artery and one at the left side, the splenic or lineal artery. Just before this division, in general its superior part, the left gastric artery is originated (Pignataro).
MATERIAL AND METHOD
Eighty nine cadavers were analyzed and came from the following Institutions: Death Verification Service of the Federal University of Sao Paulo (UNIFESP/EPM) and from the city of Sao Paulo at the Medical Faculty of Sao Paulo University (USP) and Anatomy Laboratories at the Federal University of Sao Paulo (UNIFESP/EPM), Medical Sciences Faculty of the Lusiadas University of Santos (UNILUS) and Santo Amaro University (UNISA).
Sixty-nine cadavers fixed in 10% formalin solution were dissected. Ages ranged from 21 to 82 years, of which 60 were males and nine females. They were from the Anatomy Laboratories of the Federal University of Sao Paulo, Medical Sciences Faculty of the Lusiadas University of Santos and Santo Amaro University.
Dissection of the celiac trunk of these cadavers was performed after opening of the peritoneal cavity during the classes of the graduation course.
Also, 20 non -fixed cadavers maintained in a frigorific chamber, of which 12 males and eight females, with ages ranging from 34 to 88 years were dissected during necropsies at the Death Verification Service of the city of Sao Paulo, in the Medical Faculty of Sao Paulo University (USP) and in the Federal University of Sao Paulo (UNIFESP/EPM).
To dissect the celiac trunk and the superior mesenteric artery in the fixed cadavers, the pancreas was removed or had its body sectioned or divided with the aid of a scissor. In non-fixed cadavers, the celiac trunk and the superior mesenteric artery were reached by the omentum, opening the flaccid part of the lesser omentum. Ganglions and the nervous tissue of the celiac plexus, involving the initial segment of the mentioned vessels (celiac trunk and superior mesenteric artery), were withdrawn with the aid of a pincer and scissor to allow observing disposition of these arteries from their origins.
To obtain measures proposed in this study, a digital pakimeter of Mitutoyo Corporation was used.
All preparations were photographed to illustrate the results of the present study.
Due to technical difficulties, the overall number of dissected cadavers, that is 89, could not be maintained for all the studied variables (length and diameter of the celiac trunk, distance between celiac trunk and the superior mesenteric artery).
The length of the celiac trunk was measured in 81 cadavers, from its origin up to emission of the first artery, the left gastric and/or splenic artery and, also until emission of its last artery, the common hepatic and/or splenic in 68 cadavers. The diameter of the celiac trunk was measured in the first centimeter near its origin in 77 cadavers.
The distance between the origins of the celiac trunk and the superior mesenteric artery was measured in 76 cadavers from the inferior contour of the celiac trunk up to the superior contour of the superior mesenteric artery and in case of doubt regarding the common origin of these structures, the aorta was opened to allow better visualization.
Statistical Analysis (Siegel, 1976). To compare the previously defined variables between sexes, that is, the length of the celiac trunk in relation to the left gastric and/or splenic artery, length of the celiac trunk up to the common hepatic and/or splenic artery and the distance from the celiac trunk up to the superior mesenteric artery, the non-parametric Mann-Whitney test for two independent samples was used since we had no idea whether that variables would make a Gaussian curve.
In all the cases, the rejection level for the null hypothesis was fixed in a value lower or equal to 0.05 %. (5%).
When the calculated statistics did not present a significance level, the NS was used to characterize it.
The means were calculated and were shown only for information as well as minimum and maximum values.
Mensuration of the length from the celiac trunk up to the left gastric and/or splenic artery. In male cadavers, the minimum length between those two arteries was 0.20 cm, the maximum 2.30 cm and the mean of 1.23 cm. In the female cadavers, length reached the minimum value of 0.42 cm and maximum of 1.78 with a mean of 1.18 cm.
The statistical analysis of these results revealed that measure of the celiac trunk length between male and female cadavers are not statistically significant different.
The left gastric artery, as the first branch of the celiac trunk, was observed in 55 (67.90%) out of the 81 cadavers (Fig.1). The origin of both arteries, the left gastric and splenic bifurcating as first branches was noted in six (7.41%) cadavers. In two (2.47%) the splenic artery was observed as the first branch.
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
Eighteen (22.22%) cadavers with the celiac trunk presenting their three arteries trifurcating at the same level, forming the Haller's tripod (Fig.2), were also included in this analysis.
Mensuration of the length from celiac trunk up to common hepatic and/or splenic artery. This length in male sex had a mean of 1.74 cm, with minimum length of 0.35 cm and maximum 4.0 cm. In female cadavers, the mean length was 1.74 cm, the minimum 0.82 cm and maximum 2.58 cm.
The common hepatic artery was present in 13 (19.12%) cadavers as the last artery, the splenic artery in 4 (5.88%) and both arteries at the same level, as terminal branches (Fig.1), in 33 (48.53%) out of the 68 studied cadavers.
Measures of length of the 18 (26.47%) cadavers presenting the Haller's tripod were included in this statistics.
Statistical treatment did not show statistically significant differences between sexes.
Mensuration of celiac trunk diameter. Diameter of the celiac trunk in male cadavers had a mean of 0.65 cm, with a minimum diameter of 0.45cm and maximum 0.95 cm. Diameter of the celiac trunk in female cadavers had a mean of 0.67cm, with minimum diameter of 0.40 cm and maximum of 0.90 cm.
No statistically significant differences of measures taken from the celiac trunk diameter in both sexes were observed.
Distance between celiac trunk and the superior mesenteric artery. In male cadavers, the minimum distance was 0.10 cm, maximum 1.80 cm and the mean of 0.72 cm. In female cadavers, the minimum distance was 0.29 cm, maximum 1.45 cm and mean of 0.74 cm. (Fig. 2-6).
No statistically significant differences were observed in the measures of distance between the celiac trunk and the superior mesenteric artery in relation to gender.
Branches of the celiac Trunk. When emission of the celiac trunk branches was evaluated in the 89 cadavers, we observed that the classic celiac trunk with emission of the left gastric, splenic and hepatic arteries was found in 73 (82.02%) (Figs.1 and 2). However, the Haller's tripod, in which the three arteries originated at the same level and in the terminal portion of the celiac trunk was observed in 18 (24.66%) out of the 73 cadavers or in 20.22% out of the 89 total cadavers (Fig.2).
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
In the remaining 16 cadavers (17.98%), we observed variations regarding disposition of the left gastric, splenic and hepatic arteries also regarding the number of emitted arteries.
Analysis of these variations revealed the celiac trunk emitting, besides the left gastric, splenic and hepatic arteries, a gastroduodenal artery originating at the bifurcation of the hepatic and splenic arteries in six (6.74%) cadavers (Fig.3), a gastroduodenocolic trunk in one (1.12%) (Fig. 4) and one hepatic accessory artery in two (2.25%) (Fig. 5).
[FIGURE 5 OMITTED]
In three (3.37%) cadavers, a gastrosplenic trunk with the common hepatic artery, originating at the superior mesenteric artery was observed (Fig.6), in two (2.25%), a hepatosplenic trunk and the left gastric artery independently originating at the aorta (Fig.7) and in one (1.12%) the common hepatic artery originating at the celiac trunk and the left gastric and splenic arteries originating separated at the aorta. In one (1.12%) cadaver absence of the celiac trunk was observed and the left gastric, splenic and hepatic arteries were emitted separated by the aorta (Fig. 8).
[FIGURE 6 OMITTED]
[FIGURE 7 OMITTED]
[FIGURE 8 OMITTED]
As previously observed, due to technical difficulties it was not possible to maintain the same number of samples in all the tables.
In six (7.89%) out of the 76 cadavers, a common celiacomesenteric ostium was found. This percentage was greater than that found by Michels (1951) who reported three (1%) out of 400 dissections. However, the occurrence of a common celiacomesenteric trunk, as referred by Lipshutz; Anson & McVay; Mincev & Baldzijski (1971) was not found in this study.
It was observed that the distance between the celiac trunk and the superior mesenteric artery, in 76 cadavers, ranged from 0.10 to 1.80 cm with a mean of 0.73 cm, differing from the findings of some authors who obtained the following measures: 1 to 11 mm with a mean of 3.88 mm in 140 cadavers (Brunet et al., 1993); 0.5 to 3.1 cm, with a mean of 1.6 cm in 38 (George); 1.0 to 2.0 cm in 70 (Anson & McVay) and a mean of 1.3 cm (Cauldwell & Anson) and in accordance with Michels (1951, 1953a,b) who reported a distance from 1 to 22 mm in 200 cadavers.
The celiac trunk, according to the literature, was described by von Haller (1803) apud Rio Branco as a trunk trifurcating at its termination into left gastric, splenic and common hepatic arteries.
The Haller's tripod was verified in 20.22% of the 89 cadavers dissected in the present study (Fig. 2). These results are similar to the percentages of 24 up to 25% found by Eaton (1917); Lipshutz and Michels (1953a,b) and that 33% found by Rio Branco.
Regarding the length of the Haller's tripod we obtained a mean of 1.62 cm, minimum 1.0 and maximum 2.09 cm. These results are in accordance with that of Rio Branco, who mentioned a length of up to 20 mm and Tandler, who reported 1 to 2 cm. These results differ from those found by Fumagalli & Cavallotti who mentioned 10 mm.
The classic celiac trunk that originated the three arteries (left gastric, splenic and hepatic) is also denominated complete hepatolienogastric trunk (Michels, 1951, 1953a,b). The observation of this type of normal celiac trunk found in 65% out of 200 dissections carried out by Michels (1953a,b), and in 75% out of the 83 dissections performed by Lipshutz, allowed us to consider that 82.02% out of the 82 cadavers of this study are similar to that found by Lipshutz and differ from those of Michels (1953a).
The most frequent type of celiac trunk is that originating the left gastric artery as a collateral branch before the bifurcation into hepatic and splenic artery (Eaton; Pignataro; Latarjet & Ruiz Liard).
The left gastric artery, as first branch of the celiac trunk was found in 67.90% of the cadavers analyzed in this study, which is in agreement with the 62.10% of Eaton and with 66.67% of Rio Branco. Lipshutz verified the splenic artery as first branch of the celiac trunk in 2.41%, and our results are in accordance with this percentage.
We consider the length of the celiac trunk from its origin up to bifurcation into the hepatic and/or splenic artery, which is in accordance with Pignatario and Rio Branco).
The length from the celiac trunk up to the splenic and/or hepatic artery ranged from 0.35 to 4.0 cm. These results are in agreement with that of the Rio Branco who reported a length from 5 to 40 mm and Michels (1951), who observed 8 to 40 mm and differ from that of Orts Llorca, who found up to 12 mm, that of Latarjet & Ruiz- Liard, who observed 10 to 15 mm. Also, in our study, the celiac trunk did not reach a length of 4.5 cm, as observed by Yuksel & Sargon (1992).
An explanation for length variations of the celiac trunk found in the literature was conjectured by Rio Branco and correlated with the celiac trunk division process. The celiac trunk with 20 mm or more would emit as terminal branches the hepatic and splenic arteries and as collateral branch the left gastric artery, while in those with less than 20 mm, the three branches would originate at the same level. Our results are in accordance with Rio Branco's hypothesis when we observed a Haller's tripod with 2.0 cm or more, in only four (22.22%) out of the 18 cadavers. In the 43 cadavers with hepatic and splenic arteries ending at the apex of the celiac trunk and the left gastric as collateral, only 12 (27.91%) had more than 2.0 cm in length, differing from Rio Branco's assumption.
In our studies, the mean diameter of the celiac trunk was 0.66 cm, minimum 0.40 cm and maximum 0.95 cm, similar to that of Rio Branco, who observed variations from 4 to 10 mm; Michels (1951) from 3 to 12 mm; Pignataro from 10 to 12 mm; Fumagalli & Cavallotti, 7 mm; Latarjet & Ruiz Liard a mean of 6 mm.
In the present study, other variations of the celiac trunk were verified. There is a great variation in origin of all visceral branches (Stoney & Wylie).
Out of the 89 dissected cadavers, 16 (17.98%) variations were observed. Among those, six (6.74%) celiac trunks, emitting as fourth branch a gastroduodenal artery (Fig. 3). Our results differ from that of Lipshutz), who observed a gastroduodenal artery originating in the celiac trunk in three (3.61%) out of the 83 cadavers and that from Michels (1953a,b), who found five (2.5%) in 200 dissections with the gastroduodenal artery originating in the celiac trunk or in the superior mesenteric artery without specifying the number of origins of each artery.
The emission of the right hepatic artery as the fourth branch of the celiac trunk was angiographically demonstrated by Lamarque et al. in three (2%) out of the 143 observed cases. Also, Rio Branco reported one (2%) in 50 cases. A right accessory hepatic artery (Fig. 5) was observed by us in two (2.25%) out of the 89 cadavers, which is in accordance with the percentage mentioned by the addressed authors.
An observation of a gastroduodenocolic trunk (Fig 4), as we have decided to denominate it in one (1.12%) cadaver, is not mentioned in the literature, both in the treatise and specific studies on this subject. This common trunk gave origin to the middle colic and gastroduodenal.
The official anatomic terminology did not register a name to designate the gastroduodenocolic trunk when it appears.
Rio Branco reported that the gastrosplenic trunk occurred in 4% of the cadavers. Other authors observed, by a computerized tomography in 100 patients, the common hepatic originating in the superior mesenteric artery in 3% of the patients (Sponza et al., 1993). Also, was analyzed in 107 angiographs, four (3.74%) (Mincev & Baldzijski). Our results revealed three (3.37%) in 89 cadavers (Fig. 6) in accordance with the findings of the above mentioned authors. However, our results differ from the Michel's results (1951) that found three (1.5%) in 200 cadavers.
The hepatosplenic trunk variety was concluded by Rio Branco occurring in 5% of the cases. Similarly, Michels (1953) observed 3.5 % in 200 dissections, and Mincev & Baldzijski found 2% in 107 angiographs. The observation of this variation in two (2.25%) out of the 89 cadavers in the present study (Fig. 7) led us to agree with the above mentioned authors and to disagree with Lipshutz (1917), who reported this variation in 15% out of the 83 dissections.
We are in accordance with Rio Branco when he mentioned that in the hepatosplenic variation, the gastric left artery originates in the aorta just below the celiac trunk.
Olvier et al. (1970) observed a gastrosplenic trunk and the hepatic artery originating as separated branch from aorta, being the three arteries compressed by the median arcuate ligament. In this study no similar cases could be observed.
On the other hand, in one cadaver (1.12%) the celiac trunk emitting the common hepatic artery and the left gastric and splenic arteries with independent origins in the aorta were observed by us. No similar case was observed in the researched literature.
In the literature there are rare cases of absence of celiac trunk (Yamaki et al., 1995). According to Rio Branco this variation was observed in 0.8% out of the 50 dissections. Intrasurgically, one case was observed (Morettin et al., 1995). Our results are in accordance with the literature since we could demonstrate the absence of the celiac trunk in only one case (1.12%) (Fig. 8).
Yamaki et al. observed in one case, a left gastric artery originating in the aorta anterior wall, bellow the inferior left phrenic artery, the splenic artery originating in the left side of the anterolateral wall of the aorta, 4 mm distal to the left gastric artery and the common hepatic in the right side of it, approximately 10.5 mm distal to the left gastric artery and the superior mesenteric artery at 10.4 mm distal to the common hepatic artery.
Similarly to Yamaki et al., we found one left gastric artery originating in the anterior wall of aorta, the splenic artery and the common hepatic artery with proximal origins in the median portion of the aorta, approximately 0.6 cm distal from the left gastric artery and the superior mesenteric artery originating in the anterior wall of aorta at 0.75 cm of the common hepatic artery and splenic artery (Fig. 8).
Our findings are not in accordance with Augustiniak (1965), who verified in one case of absence of celiac trunk, the inferior phrenics and left gastric artery originating in the splenic and the common hepatic in the superior mesenteric artery.
We may emphasize that authors like Michels (1951; 1953a,b) and Rio Branco found one dorsal pancreatic artery and one middle colic artery originating in the celiac trunk, this fact not found by us.
Received: 23-01-2007 Accepted: 04-03-2007
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PETRELLA, S.; RODRIGUES, C. F. S.; SGROTT, E. A; FERNANDEZ. G. J. M.; MARQUES, S. R. & PRATES. J. C. Anatomy and variations of the celiac trunk. Int. J. Morphol., 25(2):249-257, 2007.
PETRELLA, S.; RODRIGUES, C. F. S.; SGROTT, E. A; FERNANDEZ. G. J. M.; MARQUES, S. R. & PRATES. J. C. Anatomia y variaciones del tronco celiaco. Int. J. Morphol., 25(2):249-257, 2007.
Prof. Dra. Selma Petrella
Rua Rio Grande, 180 apto. 62
Sao Paulo CEP
* Selma Petrella; ** Celio Fernando de Sousa Rodriguez; *** Emerson Alexandre Sgrott; **** Geraldo Jose Medeiros Fernandes; ***** Sergio Ricardo Marques & ***** Jose Carlos Prates.
* Medical Biology Division, Adolfo Lutz Institute, Sao Paulo, Brazil. ** Department of Morphology, Federal University of Alagoas, Brazil. *** Descriptive and Topographic Anatomy Division, Vale do Itajai University, Santa Catarina, Brazil **** Descriptive and Topographic Anatomy Division, Alfenas University, Minas Gerais, Brazil. ***** Descriptive and Topographic Anatomy Division, Federal University of Sao Paulo, Brazil.