Anomalous origin of Cystic artery from Gastroduodenal artery--a case report/ origen Anomalo de la Arteria Cistica desde la Arteria Gastroduodenal--reporte de un caso.
Anatomical variations of the cystic artery are commonly encountered during cholecystectomy. In most of the cases, the cystic artery arises from the right hepatic artery. The other origins include the left hepatic artery, the proper hepatic artery, the common hepatic artery, the gastroduodenal artery, the superior pancreaticduodenal artery and the superior mesenteric artery (Williams et al., 1989; Price & Holden, 1993; Harris & Pellegrini, 1994). In addition to the variability in origin of the cystic artery, its course can also follow diverse paths, often in close proximity to the common bile duct (Price & Holden). This emphasises the importance of a thorough knowledge of the cystic arterial variations that often occur and may be encountered during both open and laparoscopic cholecystectomy. Uncontrolled bleeding from the cystic artery and its branches is a serious problem that may increase the risk of intraoperative lesions to vital vascular and biliary structures (Hugh et al., 1992; Scott-Conner & Hall, 1992). This paper presents a rare and, to our knowledge, an unreported major branch of the cystic artery, that was encountered during routine human cadaver dissection in our laboratory.
[FIGURE 1 OMITTED]
In the routine dissection of 34 year old male cadaver, we observed a case of the cystic artery (CA) having an origin from the gastroduodenal artery ( GDA) 2.5cm distal to the origin of common hepatic artery (CHA) (Fig. 1). All other branches of the celiac trunk were normal and seen taking normal course. All branches were carefully dissected and photographed.
The cystic artery (CA) originates from the following sources: right hepatic (63[+ or -]9%), hepatic trunk (26[+ or -]9%), left hepatic (5[+ or -]5%), gastroduodenal (2[+ or -]6%), superior pancreaticoduodenal (0[+ or -]3%), right gastric (0[+ or -]1%), coeliac trunk (0[+ or -]3%) and superior mesenteric (0[+ or -]8%) artery (Anson, 1963). A little difference in origin was noted by Harris & Pellegrini, where the right hepatic artery was the main contributor (75%). The other contributors were the left hepatic artery (6[+ or -]2%), hepatic artery proper (2[+ or -]2%), common hepatic artery (0[+ or -]6%), superior pancreatico-duodenal artery (0[+ or -]2%) and the superior mesenteric artery reported by Anson. In a study by Sarkar & Roy (2000) the CA originating from the gastroduodenal artery was found once in 96 cases studied (1[+ or -]04%), which is the lowest within the reported literature. During development, the extrahepatic biliary system arises from an intestinal diverticulum, which carries a rich supply of vessels from the aorta, coeliac trunk and superior mesenteric artery. Later most of these vessels are absorbed, leaving in place the mature vascular system. As the pattern of absorption is highly variable, it is not unusual for the cystic artery and its branches to derive from any other artery in the vicinity (Nowak, 1977).
Laparoscopic cholecystectomy has been accepted as the preferred method of treatment of gall bladder stones in healthy individuals. During laparoscopic cholecystectomy, dissection of a limited field is magnified on the video monitor, which indicates that a detailed anatomical knowledge of the possible variations in the anatomy of the cystic artery and its branches is very important to the surgeon (Hugh et al.; Scott-Conner & Hall). The cystic artery arising outside the hepatobiliary triangle usually passes ventral to the common hepatic duct and in some cases it may even be inferior to the cystic duct, thus becoming the first structure encountered in dissection of the inferior border of the hepatobiliary triangle by laparoscopy and has a chance of accidental injury (Hugh et al.). It is obvious that too proximal a ligation of such a cystic artery would endanger the common hepatic duct. In conclusion, identification of such variation has immense surgical importance and requires special attention in gallbladder surgeries and also helps the radiologist to perform an intraoperative cystic angiogram during hepatobiliary surgery.
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Nowak, M. Variation of the cystic artery in man. Variation of the cystic artery in man. Folia Morphologica, 36(2):89-98, 1977.
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Sarkar, A. K. & Roy, T. S. Anatomy of the cystic artery arising from the gastroduodenal artery and its choledochal branch-a case report. J. Anat., 197(3):503-6, 2000.
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Williams, P. L.; Warwick, R.; Dyson, M. & Bannister, L. H. Gray's Anatomy. Edinburgh, Churchill Livingstone, 1989. pp.76872.
Bhagath Kumar Potu
Department of Anatomy
Kasturba Medical College