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Contributors
xxv
Junichi Shindoh Hepatobiliary-Pancreatic Surgery Division, Department of
Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
ChanKaiSiang Ministry of Health Holdings Limited, Singapore, Singapore
Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
MicheleSimbolo Department of Pathology, University of Verona, Verona, Italy
SiYoungSong Division of Gastroenterology, Department of Internal Medicine, Institute of
Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
Rubens Copia Sperandio Centro de Oncologia e Hematologia Einstein Familia DayanDaycoval, Hospital Israelita Albert Einstein, São Paulo, Brazil
Akinori Suzuki Department of Gastroenterology, Graduate School of Medicine, Juntendo
University, Tokyo, Japan
Sho Takahashi Department of Gastroenterology, Graduate School of Medicine, Juntendo
University, Tokyo, Japan
YuTakahashi Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital,
Tokyo, Japan
KyoichiTakaori Department of Surgery, Nagahama City Hospital, Nagahama, Japan
Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
YusukeTakasaki Department of Gastroenterology, Graduate School of Medicine, Juntendo
University, Tokyo, Japan
NobuyukiTakemura Department of Surgery, Hepato-Biliary Pancreatic Surgery Division,
National Center for Global Health and Medicine, Tokyo, Japan
MinoruTanabe Department of Hepatobiliary and Pancreatic Surgery, Graduate School of
Medicine, Tokyo Medical and Dental University, Tokyo, Japan
KojiroTaura Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department
of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
TakuroTerada Department of Gastrointestinal Surgery, Fukui Prefecture Saiseikai Hospital,
Fukui, Japan
Elizabeth Thompson Department of Pathology, The Sol Goldman Pancreatic Cancer
Research Center, Baltimore, MD, USA
Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD,
USA
DanaTomescu Department of Anaesthesia and Critical Care, “Carol Davila” University of
Medicine and Pharmacy, Bucharest, Romania
Department of Anaesthesia and Critical Care, Fundeni Clinical Institute, Bucharest, Romania
Ko Tomishima Department of Gastroenterology, Graduate School of Medicine, Juntendo
University, Tokyo, Japan
Guido Torzilli Division of Hepatobiliary and General Surgery, Humanitas Clinical and
Research Center IRCCS, Milan, Italy
Department of Biomedical Sciences, Humanitas University, Milan, Italy
MarziaTripepi Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of
General and Hepato-Biliary Surgery, University of Verona, Verona, Italy
Katsuhiko Uesaka Department of Hepatobiliary Pancreatic Surgery, Shizuoka Cancer
Center, Shizuoka, Japan
xxvi
MichiakiUnno Department of Surgery, Tohoku University, Sendai, Miyagi, Japan
Mako Ushio Department of Gastroenterology, Graduate School of Medicine, Juntendo
University, Tokyo, Japan
Elena Usova International Association of Surgeons, Gastroenterologists and Oncologists,
Kyoto, Japan
GoWakabayashi Center for Advanced Treatment of HBP Diseases, Ageo Central General
Hospital, Saitama, Japan
Sharon M. Weber Department of Surgery, Division of Surgical Oncology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
Y. H. Andrew Wu Division of Surgical Oncology, Department of Surgery, University of
Colorado, Denver, CO, USA
WenmingWu Department of General Surgery, State Key Laboratory of Complex Severe and
Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science
and Peking Union Medical College, Beijing, China
LixiaXu Cancer Center, The First Afliated Hospital, Sun Yat-sen University, Guangzhou,
Guangdong Province, China
Department of Gastroenterology and Hepatology, The First Afliated Hospital, Sun Yat-sen
University, Guangzhou, Guangdong Province, China
Contributors
QiangXu Department of General Surgery, State Key Laboratory of Complex Severe and Rare
Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and
Peking Union Medical College, Beijing, China
MasakazuYamamoto Department of Surgery, Institute of Gastroenterology, Tokyo Women’s
Medical University, Tokyo, Japan
Yasunobu Yamashita Second Department of Internal Medicine, Wakayama Medical
University, Wakayama, Japan
HirokiYamaue Second Department of Surgery, Wakayama Medical University, Wakayama,
Japan
KenjiYoshino Department of Surgery, Nagahama City Hospital, Nagahama, Japan
Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
RaduZamr Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute,
Bucharest, Romania
Surgical Anatomy oftheLiver
KenjiYoshino, KojiroTaura, KyoichiTakaori, YosukeKasai,
andEtsuroHatano
1
Abstract
Liver is the largest internal organ in the body, occupying
2.5% of the total body weight, characterized by the complex anatomy of the internal vascular and the ductal system. Despite the recent advances in the understanding of
the physiology and pathology of the liver, the anatomy of
this organ still remains not fully dened. The detailed
anatomy of the liver described by Couinaud has been the
basis both in surgical techniques and in diagnostics and
for decades. However, the anatomic variation of the liver
is not rare, and the frequencies of variant hepatic artery,
portal vein, and bile duct have been reported to be approximately 45%, 14%, and 43%, respectively. Currently,
owing to advances in diagnostic imaging, we can predict
the anatomy of individual cases in detail before surgery.
However, not all anomalies can be reliably detected even
with the modern diagnostic tools. Hence, knowledge of
the basic anatomy and anatomical variation of the liver is
essential to ensure safe and successful hepatic surgery.
K. Yoshino (*) · Y. Kasai
Department of Surgery, Nagahama City Hospital,
Nagahama, Japan
Department of Surgery, Graduate School of Medicine, Kyoto
University, Kyoto, Japan
K. Takaori
Department of Surgery, Nagahama City Hospital,
Nagahama, Japan
Department of Surgery, Graduate School of Medicine, Kyoto
University, Kyoto, Japan
K. Taura · E. Hatano
Division of Hepato-Biliary-Pancreatic Surgery and
Transplantation, Department of Surgery, Graduate School of
Medicine, Kyoto University, Kyoto, Japan
1.1 Introduction
Many anatomists and surgeons have contributed to our current understanding of liver anatomy. The French anatomist
and surgeon Couinaud has described the anatomy of the liver
in detail and demonstrated that liver functional anatomy is
based on vascular and biliary relationships rather than external surface morphology [1]. Bismuth further improved the
concept of functional anatomy of the liver by meticulous
analysis on the distribution of the portal pedicles and the
location of the hepatic veins with the aim to improve the feasibility and safety of hepatobiliary surgery [2]. Furthermore,
there is a demand for more advanced hepatobiliary surgery
with increasing complexity, and it became mandatory for us
to carry out precise anatomical evaluation of the hepatic vasculature and biliary system preoperatively. The vascular
anatomy of the liver intricately consists of the hepatic arteries, portal veins, bile ducts, and hepatic veins. The recent
advances in hepatic surgery as well as those in endoscopic
and radiological interventions necessitate comprehensive
knowledge of the complex anatomy of the liver in order to
avoid possible complications and to achieve the most effective results. The development of imaging technologies such
as multidetector computed tomography with reconstruction
of three-dimensional angiography and high-resolution magnetic resonance cholangiopancreatography has enabled us to
carry out the anatomical evaluation of high precision [3, 4].
In this chapter, taking advantage of the next-generation
imaging technologies, we describe the surgical anatomy of
the liver with special reference to hepatic arteries, portal
veins, bile ducts, and hepatic veins.
1.2 Arterial Anatomy
Arterial supply of the liver from the common hepatic artery
(CHA) contributes 20–25% of hepatic blood inow. The
CHA proceeds laterally and branches into the proper hepatic
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_1
1
2
ab
K. Yoshino et al.
RAS
RPS
MPV
IVC
Fig. 1.1 CT imaging anatomy of the liver. (a) Typical vascular anat-
omy of the liver; (b) portal veins and hepatic arteries and segments; (c)
hepatic veins. IVC inferior vena cava, LHV left hepatic vein, LS lateral
PHA
artery (PHA) and the gastroduodenal artery. The PHA turns
upward to ascend into the hepatoduodenal ligament. In the
segment, MHV middle hepatic vein, MPV main portal vein, MS median
segment, PHA proper hepatic artery, RAS right anterior segment, RPS
right posterior segment
Table 1.1 Anatomical variations in branching patterns of the hepatic
arteries according to Michel’s classication
c
typical hepatic arterial anatomy, the PHA is divided into
right (RHA) and left hepatic arteries (LHA) [3, 5, 6]. The
LHA is located in front of and below the transverse part of
the left portal branch in 80% and behind the left portal branch
in 20% of cases [7, 8]. The middle hepatic artery (MHA)
originates from LHA in 54%, from RHA in 34%, from trifurcation with LHA and RHA from PHA in 8%, and from CHA
in 4% [8]. The cystic artery branches off the RHA in the
hepatocystic triangle located between the cystic duct (CD)
and the common bile duct (CBD). However, the extra-hepatic
arterial anatomies are especially complex, showing many
anatomic variations. The typical vascular anatomy of the
liver is shown in Fig.1.1 and the anatomical variation of the
hepatic arteries according to the Michel’s classication is
described in Table1.1 [9]. A replaced RHA may most commonly originate from the superior mesenteric artery (SMA)
in 10–21% of individuals (Fig.1.2) while a replaced left gastric artery (LGA) may arise from the LHA in 3–10% [5, 10,
11]. Also, an accessory LHA and RHA may exist in 1–8%.
Another variant to this anatomy is a CHA which may come
Type Pattern
1 Normal (RHA, MHA, LHA) 55
2 Replaced LHA from LGA 10
3 Replaced RHA from SMA 11
4 Replaced MHA from SMA
Replaced LHA from LGA
5 Small LHA and an accessory LHA from LGA 8
6 Small RHA and an accessory RHA from SMA 7
7 RHA and an accessory RHA from SMA
LHA and an accessory LHA from LGA
8 Replaced RHA from SMA and an accessory
LHA from LGA
or
Replaced LHA from LGA and an accessory
RHA from SMA
9 CHA absent—the entire hepatic trunk derived
from SMA
10 CHA absent—the entire hepatic trunk derived
from LGA
CHA common hepatic artery, LGA left gastric artery, LHA left hepatic
artery, MHA middle hepatic artery, RHA right hepatic artery, SMA supe-
rior mesenteric artery
RHV
MS
LS
LHV
MHV
Population
(%)
1
1
2
2.5
0.5
off the SMA in about 1.5% of the population [5, 10, 11].
The intrahepatic arteries harbor relatively less anatomical
variation as compared to the extrahepatic artery. Within the
liver or extra-hepatically, the RHA divides into anterior and
posterior segmental arteries, which further divide to supply
the respective subsegments in almost all cases [2, 7]. The
anatomic variations, such as LHA running to the right side of
the umbilical portion of the portal vein and the posterior segmental artery running to the cranial side of the RPV, are
potentially very important, as they may alter the surgical procedure of a hepatectomy for biliary tract cancer. The arterial
tributary toward the caudate lobe also originates from the
RHA and supplies the caudate process and the right side of
1 Surgical Anatomy oftheLiver
LHA
CHA
Replace RHA
SMA
Fig. 1.2 CT imaging of the replaced right hepatic artery arising from
the superior mesenteric artery. The right hepatic artery arising from the
superior mesenteric artery (type 3 according to Michel’s classication)
is one of the most common anomalies. CHA common hepatic artery,
LHA left hepatic artery, RHA right hepatic artery, SMA superior mesen-
teric artery
the caudate lobe. The medial segmental artery supplies the
quadrate lobe. The lateral segmental artery divides into superior and inferior arteries for the respective subsegments.
Furthermore, the left hepatic artery gives off a branch for the
caudate lobe, supplying its left side.
1.3 Portal Venous Anatomy
The majority of the hepatic blood inow (75–80%) comes
from the portal vein. The portal vein bifurcates into the right
and left branches before entering the liver. In general, portal
veins are found posterior to the hepatic arteries and bile ducts
in their lobar and segmental distribution.
The left branch of the portal vein runs horizontally with a
long extrahepatic course and commonly gives off a small
branch to the caudate lobe. However, the branch to the caudate lobe may arise from the main or right portal vein, since
the caudate portal vein inow is variable. The left branch of
the portal vein crosses the umbilical segment, where it gives
rise to branches for segment II prior to the division into
branches to segment III and segment IV.
The right branch of the portal vein is located anterior to
the caudate process, and it gives off a branch to the caudate
lobe and then an anterior branch and a posterior one.
Eventually, the anterior and posterior branches divide into
branches for the segments V and VIII, and those for VI and
VII, respectively.
The branching patterns of the portal vein according to
Akgul’s classication are shown in Table1.2 [12]. So-called
classical portal anatomy (Type I) is present in 65–99% of the
population. In 15% of individuals, the portal vein trifurcates
into right anterior, right posterior, and left portal vein at a
3
Table 1.2 Anatomical variations in blanching patterns of the portal
veins according to Akgul’s classication
Type Pattern
I Bifurcation of MPV (classical) 86.2
II Trifurcation of MPV 12.3
III RPPV from MPV+LPV and RAPV as a
common trunk
IV RPPV from MPV+RAPV from LPV 0.9
V LPV absent 0
VI RPV with branches absent 0
VII LPV from RAPV, horizontal segment of LPV
absent
VIII MPV divides into RAPV and RPPV, LPV
from RAPV
LPV left portal vein, MPV main portal vein, RAPV right anterior portal
vein, RPPV right posterior portal vein, RPV right portal vein
Population
(%)
0.3
0
0.3
common place [12]. Also, the right posterior portal vein may
arise from the portal vein trunk instead of the right portal
vein in 7% of individuals [13]. In previous reports, types 5,
6, and 7 are also present in less than 0.3% [13, 14]. Depending
on whether these anatomical abnormalities are present or
not, alteration of the surgical procedure may be considered.
Furthermore, anatomical variation may not be limited to the
portal vein but may also coexist in the artery and bile ducts.
For example, in a donor hepatectomy for living donor liver
transplantation, a left trisegmental resection is required
instead of a right hepatectomy in cases of type III anatomical
variation with arterial variation (Fig.1.3) [15]. Hence, surgeons need to plan their operative procedures in advance
with possible anatomical variations in mind.
1.4 Biliary Anatomy
The segmental biliary branches accompany the arterial and
venous portals surrounded by the Glissonian sheath.
Generally, bile ducts II, III, and IV constitute the left
hepatic duct (LHD), and V, VI, VII, and VIII form the right
hepatic duct (RHD). Segment I is commonly drained by
several ducts into the RHD and LHD (80%), and therefore,
surgeons should be mindful of the variable anatomy of bile
ducts when operating at the hilum of the liver. LHD and
RHD are located superior to the primary branches of portal
vein, and they join in front of and right of the portal vein
trunk. As the common hepatic duct (CHD) courses caudally, it is joined by the CD to form the CBD which empties into the duodenum.
The anatomical pattern of the bile ducts consists of six
types according to Smadja and Blumgart’s classication
(Table1.3) [16]. The classic biliary anatomy appears in about
60% of the population [17]. The most common anatomic
variation of the bile duct is trifurcation in 11–14% of the
4
ab
RAPV
RAHA
RPPV
K. Yoshino et al.
LPV
c
RAD
LD
RPHA
RPD
Resection line
Fig. 1.3 Anatomical variation of the hepatic vasculature in a donor
who underwent a left trisegmental resection of the liver for living donor
liver transplantation. (a) The right anterior hepatic artery arises from
the left hepatic artery. (b) The right anterior portal vein branches off
from the umbilical portion. (c) The common hepatic duct trifurcated
Table 1.3 Anatomical variations in drainage patterns of the bile ducts
according to Smadja and Blumgart’s classication
Type Pattern
I Normal 57
II Triple conuence of RASD, RPSD, and LHD 12
III Lower drainage of
RPSD into CHD 16
RASD into CHD 4
IV Aberrant drainage of
RPSD into LHD 5
RASD into LHD 1
V CHD is formed by union of two or more ducts
from either lobe
VI RPSD into CD 2
CD cystic duct, CHD common hepatic duct, LHD left hepatic duct,
RASD right anterior sectoral duct, RPSD right posterior sectoral duct
Population
(%)
3
into the left, anterior, and posterior ducts. LD left bile duct, LPV left
portal vein, RAD right anterior bile duct, RAHA right anterior hepatic
artery, RAPV right anterior portal vein, RPD right posterior bile duct,
RPHA right posterior hepatic artery, RPPV right posterior portal vein
1.5 Venous Anatomy
Blood from the liver is drained into the inferior vena cava
(IVC) by three major hepatic veins and a series of dorsal
hepatic veins. In 60% of the cases, the middle (MHV) and
left hepatic veins (LHV) merge to form a common trunk
before draining into the IVC [20].
The LHV lies in the upper part of the left ssure. It
drains segment II, III and IV.The middle hepatic vein lies
in the median ssure and drains segments IV, V, and
VIII.The right hepatic vein (RHV) is typically larger, with
a short extrahepatic course, and drains segments V–VII
and a part of the segment VIII.The variations of three
major hepatic veins described by Sureka are shown in
Table1.4 [21].
The minor hepatic veins including the short hepatic, middle
right hepatic, and right inferior hepatic vein emerge in the
cases. The right posterior superior duct (RPSD) draining into
the CHD is present in 7–16% and right anterior superior duct
(RASD) draining into the CHD is observed in 1–4% [18, 19].
When performing a left hepatectomy in a liver transplant
donor, positive recognition of this aberration is necessary to
lower portions of the retrohilar space and immediately drain
into the IVC, draining the territories immediately adjacent to
it. The liver volume drained by these minor hepatic veins and
three major hepatic veins is shown Table 1.5 [22]. The area
drained by these minor veins is not small. When mobilizing
prevent bile leakage and obstruction.
1 Surgical Anatomy oftheLiver
5
Table 1.4 Anatomical variations in the number and branching patterns
of hepatic vein described by Sureka
Pattern Population (%)
RHV variations
Single RHV 92
Early branching of RHV 40
2 RHV:
Common trunk 5.4
Independent drainage 1.8
3 RHV:
Common trunk 0.6
Independent drainage 0
Accessory inferior RHV 37
Small RHV with well-developed MHV 1.2
MHV and LHV variations
Common trunk of MHV and LHV 81
Independent drainage of LHV and MHV into IVC 19
IVC inferior vena cava, LHV left hepatic vein, MHV middle hepatic
vein, RHV right hepatic vein
Table 1.5 Volume of venous drainage areas from each drainage vein
Drainage vein Volume (ml) % of total liver volume
Major hepatic vein
LHV 234.2±61.6 20.7±4
MHV 369.3±96.6 32.7±7
RHV 456.7±188.1 39.6±12
Minor hepatic vein
Middle right hepatic vein 88.4±53.7 8.0±4
Inferior right hepatic vein 117.3±75.6 10.6±6
LHV left hepatic vein, MHV middle hepatic vein, RHV right hepatic
vein
the liver, especially during major hepatectomies, it is imperative to maintain awareness of vascular tributaries from the IVC
at all times.
1.6 Conclusion
Both intra and extrahepatic vasculobiliary anatomies are
complex with the existence of many common and uncommon
anatomic variations. Preoperative identication of these anatomies is mandatory for us to create the optimal surgical plan
and to reduce postoperative complications. Moreover,
advances in intraoperative mapping and parenchymal resection techniques have made and are making liver surgery safer
and more effective [23]. Surgeons as well as gastroenterologists,
oncologists, radiologists, and other specialists should respect
the complexity and nuances of the anatomical structure of the
liver, which require lifelong learning.
Acknowledgments The authors have no conicts of interest to
disclose.
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15. Taura K, Kaido T, Anazawa T, Yagi S, Okajima H, Uemoto
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Surgical Anatomy ofthePancreas
AkihikoHoriguchi, MasahiroIto, YukioAsano,
SatoshiArakawa, HiroyukiKato, andMasahiroShimura
2
Abstract
In gastroenterological surgery, pancreatoduodenectomy is
a difcult operation and requires solid anatomical knowledge and skill to perform the procedure itself and be
safely completed. Venous bleeding because of the venous
congestion of the pancreatic head and duodenum may be
encountered when the vein that ows from the pancreatic
head to the superior mesenteric vein is cut when performing a pancreatoduodenectomy, and this may hinder subsequent procedures. It is possible to prevent the congestion
of the pancreatic head and duodenum by dealing with the
incoming artery from the pancreatic head early in the
operation. This incoming artery is the inferior pancreatic
duodenal artery. Although the bifurcation of the inferior
pancreatic duodenal artery takes multiple forms, an
artery-rst approach is a useful method for safely performing surgery because it allows conrmation prior to
surgery. Using this method, not only can the amount of
intraoperative bleeding be reduced but dissection of the
lymph nodes and nerve plexus around the superior mesenteric artery can also be safely and reliably performed for
the cancer of the pancreatic head. In this study, we report
our results on the anatomy of the veins and arteries of the
pancreatic head and duodenum based on multidetector
computed tomography imaging, which is useful when
performing a pancreatoduodenectomy.
2.1 Introduction
pleted. When performing a PD, venous bleeding because of
the venous congestion of the pancreatic head and duodenum
may be encountered when the vein that ows from the pancreatic head to the superior mesenteric vein (SMV) is cut.
This bleeding may hinder subsequent procedures. It is possible to prevent the congestion of the pancreatic head and
duodenum by dealing with the incoming artery from the pancreatic head, the inferior pancreatic duodenal artery (IPDA),
early in the operation. This is referred to as an artery-rst PD
[1] or an IPDA-approached PD [2–4]. Not only can the
amount of intraoperative bleeding be reduced using such
methods, but dissection of the lymph nodes and nerve plexus
around the superior mesenteric artery (SMA) can be safely
and reliably performed. In recent years, laparoscopic PD has
been increasingly utilized, making it all the more important
to determine the anatomical structure of the pancreatic head.
In this study, we will report our results on performing the
dissection of veins and arteries of the pancreatic head and
duodenum primarily using multidetector computed tomography (MDCT) imaging.
2.1.1 Arteries ofthePancreatic Head/
Duodenum
The pancreatic head is controlled by blood ow from the
gastroduodenal artery (GDA) and SMA, and the arteries of
the pancreatic head form arcades on the anterior and posterior surfaces. The branching patterns and hemodynamics of
these arteries can vary.
In gastroenterological surgery, pancreatoduodenectomy
(PD) is a difcult operation that requires a solid anatomical
knowledge and skill in the procedure itself to be safely com-
A. Horiguchi (*) · M. Ito · Y. Asano · S. Arakawa · H. Kato
M. Shimura
Department of Gastroenterological Surgery, Fujita Health
University School of Medicine Bantane Hospital, Nagoya, Japan
e-mail: akihori@fujita-hu.ac.jp
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_2
2.1.1.1 IPDA
The IPDA normally bifurcates from the rst jejunal artery,
running from the dorsal side of the SMA to the left, across to
the right dorsal side and branching into the posterior inferior
pancreaticoduodenal artery (PIPDA) and the anterior inferior pancreaticoduodenal artery (AIPDA). A report by
researchers regarding the morphology of the IPDA prior to
7
8
A. Horiguchi et al.
ab c
PIPDA
AIPDA
Fig. 2.1 Variation in the origin of the inferior pancreaticoduodenal
artery (referred from Ref. 4). (a) A type in which the IPDA formed a
common vessel with the rst jejunal branch. IPDA inferior pancreaticoduodenal artery, FJA rst jejunal artery. (b) A type in which the IPDA
branched directly from the superior mesenteric artery. IPDA inferior
pancreaticoduodenal artery. (c) A type in which the PIPDA and AIPDA
branched separately. PIPDA posterior inferior pancreaticoduodenal
artery, AIPDA anterior inferior pancreaticoduodenal artery, IPDA infe-
IPDA+FJA IPDA independent AIPDA/PIPDA independent
PIPDA
AIPDA
IPDA
72.2% 18.8% 9.0%
IPDA
rior pancreaticoduodenal artery, FJA rst jejunal artery, PIPDA poste-
rior inferior pancreaticoduodenal artery, AIPDA anterior inferior
pancreaticoduodenal artery, IPDA+FJA a type in which the IPDA
formed a common vessel with the rst jejunal branch, IPDA independent, a type in which the IPDA branched directly from the superior
mesenteric artery, AIPDA/PIPDA independent, a type in which the
AIPDA and PIPDA branched separately
PIPDA
AIPDA
and after surgery based on MDCT images showing artery
structure [3] revealed three different types: the type that
forms a common trunk with the rst jejunal artery (72%)
(Fig.2.1a), the type that directly bifurcates from the SMA
(18.7%) (Fig.2.1b), and the type that bifurcates separately
before the SMA and after the IPDA (9.3%) (Fig.2.1c) [4].
Moreover, when performing a PD as mentioned above,
bleeding because of congestion from the PD side may be
encountered during the operation. Dealing rst with the
arteries that ow into the head of the pancreas, namely GDA
and IPDA, can prevent PD-related venous bleeding and
reduce the overall amount of bleeding. In terms of the
approaches of easily conrming the IPDA using MDCT, we
reported that observing a common trunk with the rst jejunal
artery or independent branching directly from the SMA can
conrm the beginning of the middle colic artery (MCA).
From there the rst jejunal artery can be conrmed on the
dorsal side within 2cm on the central side along the SMA
[4]. With the independently branching type, the AIPDA can
be conrmed within 2cm of the MCA origin to the central
side, and the PIPDA can be conrmed within 2cm of the
beginning of the SMA on the downstream side [5].
Furthermore, with the type where the right hepatic artery
branches from the SMA, many cases have branching of the
PIPDA from the right hepatic artery. Therefore, an easy way
of conrming the IPDA is to cranially lift the transverse
colon to conrm MCA branching on the ventral side from
the SMA, release the Treitz ligament, and verify the IPDA
from the left side of the SMA (Treitz ligament approach).
2.1.1.2 Posterior Superior Pancreatoduodenal
Artery (PSPDA)
PSPDA is the rst branch of GDA that bifurcates from the
common hepatic artery (CHA) and normally passes from the
left side of the anterior surface of the common bile duct from
a point 1–2cm from the origin of the GDA.After this point,
it passes from the posterior surface of the common bile duct
to the pancreatic parenchyma. In rare cases, there is branching from the proper hepatic artery (PHA). Moreover, the
PSPDA has a branch that nourishes the main papilla from the
lower bile duct around the dorsal side along the common bile
duct.
2.1.1.3 Anterior Superior Pancreatoduodenal
Artery (ASPDA)
After the GDA branches into the PSPDA, it branches into the
right gastroepiploic artery, which runs to the greater curvature of the gastric pyloric antrum, and the ASPDA, which
runs between the pancreatic parenchyma and the duodenum
from the anterior to the posterior surface of the pancreas. The
ASPDA has ne branches that reach into the duodenum and
pancreatic parenchyma and forms an anterior arcade from
the duodenum on the anterior surface of the papilla of Vater.
The arteries of the papilla of Vater are nourished by the