Abstract
Purpose
While laparoscopic cholecystectomy can be a routine procedure when biliary anatomy is normally located, cystic artery variations can easily disorientate the inexperienced surgeon to the anatomy of the hepatobiliary triangle. This study presents the clinically important anatomical variations of the cystic artery.
Methods
PubMed, Medline, Cochrane Database of Systematic Reviews, and Google Scholar databases were searched to conduct a review of the existing English literature on the clinically important cystic artery variations. An aberrant vessel was defined as a vessel that originated from an atypical source and/or one that was present in a specimen in addition to the normal vessel.
Results
The cystic artery originated typically from the right hepatic artery (79.02 %) and was found in the hepatobiliary triangle in only 5427 of 6661 (81.5 %) cases. Clinically important cystic artery variations are (1) the cystic artery located anterior to the common hepatic duct or common bile duct found in 485 of 2704 (17.9 %) and 228 of 4202 (5.4 %) of cases, respectively, (2) the cystic artery located inferior to the cystic duct found in 38 of 770 (4.9 %) of cases, (3) short cystic arteries found in 98 of 1037 (9.5 %) cases and (4) multiple cystic arteries found in (8.9 %) of cases.
Conclusion
These variations are common in the general population and can lead to inadvertent ligation of biliary ducts or aberrant vessels. Therefore, it is important for the hepatobiliary surgeon to be aware of these vascular anomalies to avoid operative complications.
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References
Anson BJ (1956) Anatomical considerations in surgery of the gall bladder. J Mich State Med Soc 55:671–672
Ata AH (1991) Cystic artery identification during laparoscopic cholecystectomy. J Laparoendosc Surg 1:313–318
Bakheit MA (2009) Prevalence of variations of the cystic artery in the Sudanese. East Mediterr Health J 15:1308–1312
Balija M, Huis M, Nikolic V, Stulhofer M (1999) Laparoscopic visualization of the cystic artery anatomy. World J Surg 23:703–707
Benson EA, Page RE (1976) A practical reappraisal of the anatomy of the extrahepatic bile ducts and arteries. Br J Surg 63:853–860
Bergamaschi R, Ignjatovic D (2000) More than two structures in Calot’s triangle. A postmortem study. Surg Endosc 14:354–357
Bergman RA, Thompson SA, Afifi AK, Saadeh F (1988) Cardiovascular system. In: Compendium of human anatomic variation: text, atlas, and world literature. Urban & Schwarzenberg, München, pp 78–79
Browne EZ (1940) Variations in origin and course of the hepatic artery and its branches. Surgery 8:424–445
Carbajo MA, Martín del Omo JC, Blanco JI, Cuesta C, Martín F, Toledano M, Atienza R, Vaquero C (1999) Congenital malformations of the gallbladder and cystic duct diagnosed by laparoscopy: high surgical risk. JSLS 3:319–321
Chen TH, Shyu JF, Chen CH, Ma KH, Wu CW, Lui WY, Liu JC (2000) Variations of the cystic artery in Chinese adults. Surg Laparosc Endosc Percutan Tech 10:154–157
Chen X, Luo D, Li S, Mao J, Zhou Z, Yu S, Duan Z (1996) Experience in prevention of serious complications of laparoscopic cholecystectomy. Chin Med J (Engl) 109:223–227
Conner CEH, Dawson DL (2009) The abdominal region. Operative anatomy, 3rd edn. Lippinocott Willliams & Wilkins, Philadelphia, pp 428–429
Daseler EH, Anson BJ, Hambley WC, Reimann AF (1947) The cystic artery and constituents of the hepatic pedicle; a study of 500 specimens. Surg Gynecol Obstet 85:47–63
de Silva M, Fernando D (2001) Anatomy of the Calot’s triangle and its relevance to laparoscopic cholecystectomy. Ceylon Med J 46:33–34
Ding YM, Wang B, Wang WX, Wang P, Yan JS (2007) New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy. World J Gastroenterol 13:5629–5634
Eisendrath DN (1918) Anomalies of the bile ducts and blood vessels: as the cause of accidents in biliary surgery. JAMA 71:864–867
Fathy O, Zeid MA, Abdallah T, Fouad A, Eleinien AA, el-Hak NG, Eleibiedy G, el-Wahab MA, Sultan A, Anwar N, Ezzat F (2003) Laparoscopic cholecystectomy: a report on 2000 cases. Hepatogastroenterology 50:967–971
Flint ER (1923) Abnormalities of the right hepatic, cystic, and gastroduodenal arteries, and of the bile-ducts. Br J Surg 10:509–519
Flisiński P, Szpinda M, Flisiński M (2004) The cystic artery in human foetuses. Folia Morphol (Warsz) 63:47–50
Futara G, Kinfu Y (2001) Anatomical variations of gallbladder and biliary ducts among Ethiopians. Ethiop Med J 39:173–184
Halvorsen JF, Myking AO (1971) The arterial supply and venous drainage of the gall-bladder. A study of one hundred autopsies. Acta Chir Scand 137:659–664
Hasan MM, Reza E, Khan MR, Laila SZ, Rahman F, Mamun MH (2013) Anatomical and congenital anomalies of extra hepatic biliary system encountered during cholecystectomy. Mymensingh Med J 22:20–26
Hugh TB, Kelly MD, Li B (1992) Laparoscopic anatomy of the cystic artery. Am J Surg 163:593–595
Imran M, Hasan A, Masood R, Ullah S, Taimur M (2011) Control of cystic artery in Laparoscopic Cholecystectomy: to clip or to use monopolar electrocautery. Pak J Med Sci 27:981–998
Jayatilaka AD (1988) Observations on the cystic arteries in 100 cadavers. Ceylon Med J 33:19–21
Johnston EV, Anson BJ (1952) Variations in the formation and vascular relationships of the bile ducts. Surg Gynecol Obstet 94:669–686
Larobina M, Nottle PD (2005) Extrahepatic biliary anatomy at laparoscopic cholecystectomy: is aberrant anatomy important? ANZ J Surg 75:392–395
Lin PH, Chaikof EL (2000) Embryology, anatomy, and surgical exposure of the great abdominal vessels. Surg Clin North Am 80:417–433
Lipshutz B (1917) A composite study of the coeliac axis artery. Ann Surg 65:159–169
Martin IG, Dexter SP, Marton J, Gibson J, Asker J, Firullo A, McMahon MJ (1995) Fundus-first laparoscopic cholecystectomy. Surg Endosc 9:203–206
Mau Lo C, Ng KK (2012) The Gastrointestinal Tract. (2012). In: Fischer JE (ed) Fischer’s mastery of surgery, 6th edn, Vol. 1. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, pp 1158–1159
Michels NA (1966) Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg 112:337–347
Mizumoto R, Suzuki H (1988) Surgical anatomy of the hepatic hilum with special reference to the caudate lobe. World J Surg 12:2–10
Mlakar B, Gadzijev EM, Ravnik D, Hribernik M (2003) Anatomical variations of the cystic artery. Eur J Morphol 41:31–34
Moosman DA (1975) Where and how to find the cystic artery during cholecystectomy. Surg Gynecol Obstet 141:769–772
Nagral S (2005) Anatomy relevant to cholecystectomy. J Minim Access Surg 1:53–58
Nowak M (1977) Variation of the cystic artery in man. Folia Morphol (Warsz) 36:89–98
Nye D, Hardy KY (1970) An unwelcome cystic artery. Aust N Z J Surg 40:84–86
Oddsdóttir M, Hunter JG (2005) Gallbladder and the extra heptic biliary system. In: Brunicardi FC (ed) Schwartz’s principles of surgery, 8th edn. McGraw-Hill, Health Pub. Division, New York, pp 1204–1206
Osemlak J, Siwek R (1984) The arterial supply of the extrahepatic biliary ducts in newborns and infants. Folia Morphol (Warsz) 43:137–143
Osler GF, Dow RS (1945) Variations and anomalies of the biliary duct system and its associated blood supply. Western J Surg Ob Gy 53:316–321
Rubin GD, Walker PJ, Dake MD, Napel S, Jeffrey RB, McDonnell CH, Mitchell RS, Miller DC (1993) Three-dimensional spiral computed tomographic angiography: an alternative imaging modality for the abdominal aorta and its branches. J Vasc Surg 18:656–664
Saidi H, Karanja TM, Ogengo JA (2007) Variant anatomy of the cystic artery in adult Kenyans. Clin Anat 20:943–945
Sato Y (2013) Dorsal aorta formation: separate origins, lateral-to-medial migration, and remodeling. Dev Growth Differ 55:113–129
Scott-Conner CE, Hall TJ (1992) Variant arterial anatomy in laparoscopic cholecystectomy. Am J Surg 163:590–592
Sebben GA, Rocha SL, Sebben MA, Parussolo Filho PR, Gonçalves BH (2013) Variations of hepatic artery: anatomical study on cadavers. Rev Col Bras Cir 40:221–226
Skandalakis JE, Colborn GL, Weidman TA, Foster RS Jr, Kingsnorth AN, Skandalaki LJ, Skandalakis PN, Mirilas PS (2004) Extrahepatic Biliary Tract and Gallbladder. Skandalakis’ surgical anatomy: the embryologic and anatomic basis of modern surgery, vol 2. PMP, Athens, pp 1122–1126
Stremple JF (1986) The need for careful operative dissection in Moosman’s area during cholecystectomy. Surg Gynecol Obstet 163:169–173
Sugita R, Yamazaki T, Fujita N, Naitoh T, Kobari M, Takahashi S (2008) Cystic artery and cystic duct assessment with 64-detector row CT before laparoscopic cholecystectomy. Radiology 248:124–131
Suzuki M, Akaishi S, Rikiyama T, Naitoh T, Rahman MM, Matsuno S (2000) Laparoscopic cholecystectomy, Calot’s triangle, and variations in cystic arterial supply. Surg Endosc 14:141–144
Talpur KA, Laghari AA, Yousfani SA, Malik AM, Memon AI, Khan SA (2010) Anatomical variations and congenital anomalies of extra hepatic biliary system encountered during laparoscopic cholecystectomy. J Pak Med Assoc 60:89–93
Torres K, Chrościcki A, Golonka A, Torres A, Staśkiewicz G, Palczak R, Ceja-Sanchez JM, Ceccaroni M, Drop A (2009) The course of the cystic artery during laparoscopic cholecystectomy. Folia Morphol (Warsz) 68:140–143
Walker TG (2009) Mesenteric vasculature and collateral pathways. Semin Intervent Radiol 26:167–174
Wang X, Shah RP, Maybody M, Brown KT, Getrajdman GI, Stevenson C, Petre EN, Solomon SB (2011) Cystic artery localization with a three-dimensional angiography vessel tracking system compared with conventional two-dimensional angiography. J Vasc Interv Radiol 22:1414–1419
Zubair M, Habib L, Mirza RM, Cnanna MA, Yousuf M, Quraishy MS (2012) Anatomical variations of cystic artery: telescopic facts. Med J Malaysia 67:494–496
Acknowledgments
The authors wish to thank Jessica Holland (CMI), MS, Medical Illustrator for the creation of her illustrations used in this publication. The authors also wish to extend their gratitude to the individuals who donated their bodies without whom this review would not have been possible.
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All authors declare that there are no financial associations and no conflict of interest.
Ethical considerations
This study used already publicly available data and is therefore exempt from review by the IRB. The specimens used for images are protected under IRB approval (06014) as issued by St. George’s University.
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Andall, R.G., Matusz, P., du Plessis, M. et al. The clinical anatomy of cystic artery variations: a review of over 9800 cases. Surg Radiol Anat 38, 529–539 (2016). https://doi.org/10.1007/s00276-015-1600-y
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DOI: https://doi.org/10.1007/s00276-015-1600-y