During Whipple's pancreaticoduodenectomy for a periampullary carcinoma, the surgeon encounters a replaced right hepatic artery arising from the superior mesenteric artery (SMA) running posterior to the portal vein. What is the most significant intraoperative implication of this anatomical variant?
- A The portal vein must be divided and reconstructed
- B The replaced right hepatic artery must be identified and preserved during SMA dissection to prevent right hepatic ischaemia ✓
- C The bile duct can be divided at a higher level without concern about hepatic arterial supply
- D The gastroduodenal artery ligation is contraindicated in this variant
Explanation
A replaced right hepatic artery (arising from SMA, present in ~15-20% of individuals) courses posterior to the portal vein in the hepatoduodenal ligament before entering the liver. During Whipple's procedure, failure to identify and preserve this vessel during SMA or uncinate process dissection can result in right hepatic ischaemia, bile duct ischaemia, and anastomotic complications. Surgeons must perform careful preoperative CTA and intraoperative dissection to identify and protect this variant. Portal vein reconstruction is unrelated to this variant unless invaded by tumour. GDA ligation does not depend on this variant directly.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.