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194 V. Dudeja and Y. Fong
due to leak of bile from the cut surface of the
remnant rather than from major bile duct injury.
The ongoing output from percutaneously placed
drain suggests the presence of biliary fistula.
Any evidence of biliary obstruction (intrahepatic
biliary radical dilatation on imaging or elevated
bilirubin which does not show a trend toward
normalization), should prompt decompression
of biliary system. The decompression is best
achieved by percutaneous transhepatic route,
though it may rarely be possible through endoscopic retrograde cholangiopancreatography
(ERCP; see below).
Once the patient is stabilized and the collection is adequately drained, more information is
needed to guide further management. The site of
injury to the biliary system, severity of injury, adequacy of drainage, and the presence or absence
of distal obstruction need to be ascertained. A
good quality follow-up liver protocol CT scan can
suggest the presence of any undrained collections
and information about associated vascular injury.
Contrast study through the drain can suggest the
site of large bile duct injury (if it shows communication with biliary system) and also evaluate
for presence of distal obstruction (if contrast does
not drain into the intestines) (Fig. 19.2b). Further
management depends on the presence or absence
of distal obstruction.
No Evidence of Distal Obstruction with Fistula
If no distal obstruction is suspected (contrast
study through the percutaneous drain drains
freely into the biliary system and then into the
duodenum and there is no intrahepatic biliary
radical (IHBR) dilatation), then an ERCP and
sphincterotomy can decompress the biliary system and provide radiologic evaluation of distal
biliary system and site of leak (Fig. 19.2b). In
such cases, prolonged conservative management
with nutrition, correction of electrolyte and fluid
deficits due to fistula losses, replacement of fat
soluble vitamins, and treatments of infection is
in order. Many fistulas with no distal obstruction
will heal with conservative management and endoscopic stenting.
Evidence of Distal Obstruction with Fistula
If distal obstruction is suspected on the drain
study or on CT scan then ERCP is rarely of
utility. In such circumstances, the goal is to adequately drain the biliary system to prevent adverse consequences of biliary obstruction (inadequate remnant hypertrophy, cirrhosis, and
portal hypertension). The biliary system may
already be adequately decompressed through
the fistula. However, if any suggestion of inadequate decompression is present, e.g., dilated
IHBR on CT scan or ultrasound (US) or elevated
bilirubin, then adequate drainage of the biliary
system with percutaneous transhepatic approach
is in order (Fig. 19.2b). Once all the collections
are drained and the biliary system is adequately
decompressed, conservative management should
be instituted and the surgeon should wait for
4–6 weeks to let the inflammation settle down
before attempting operative correction.
Evidence of Distal Obstruction but no Fistula
In patients who present with stricture without any
fistula, the foremost priority is to decompress
the biliary system. A liver protocol CT scan or
US done to evaluate for the etiology of elevated
bilirubin will demonstrate dilated intrahepatic
biliary radicals. Drainage in these patients is
best achieved through percutaneous transhepatic
method (Fig. 19.2b). Drainage catheter also helps
in identification of ductal structures intraoperatively at the time of operative repair, by palpation.
Detailed information about the ductal anatomy is critical in planning operative repair of
the biliary stricture. This detail can be provided
by cholangiography performed through the percutaneously placed drainage tube (Fig. 19.2c)
or through magnetic resonance cholangiopancreatography (MRCP). MRCP not only
provides striking images and detailed anatomic
information but can also help in evaluation of
liver parenchyma as well as relationship of ducts
with vascular structures (Fig. 19.2b).
19519 Contralateral Bile Duct Injury During Hepatic Resection
Fig. 19.3 Essentials of anatomy and anatomical altera-
tions for biliary reconstruction. a Normal anatomy of
biliary system. The right hepatic duct has a short extrahepatic course. On the other hand, the left hepatic duct
has a long extrahepatic course and runs transversely at the
base of segment IV before entering the umbilical fissure.
In the umbilical fissure, the left hepatic duct gives rise
to segment IVa and IVb ducts on the right and segment
II and III ducts on the left. b Schematic demonstrating
the lowering of hilar plate. Left portal pedicle runs transversely between quadrate lobe ( Q) and caudate lobe ( CL).
Definitive Management
Anatomy Relevant to Operative Repair of Biliary Outflow of Remnant
In contrast to the biliary anatomy of the right
hemiliver, the left biliary system anatomy is
relatively consistent. Also, fortuitously, the left
hepatic duct has a long extrahepatic course as
it runs along the undersurface of segment IVb.
In this transverse course, the left hepatic duct is
accompanied by left portal vein and this portal
diad (notice the absence of left hepatic artery,
normal or variant) is ensheathed in the peritoneal reflection of the gastrohepatic ligament
(Fig. 19.3a). Thus, the left duct can be exposed
Division of the reflection of Glisson’s capsule onto the
gastrohepatic ligament in the plane shown by the arrow
lowers the hilar plate and exposes the left hepatic duct
which is situated deeper to the portal vein. c Schematic
demonstrating how hypertrophy of the left liver after right
hepatectomy displaces the hilum posteriorly and laterally
and also changes the normal orientation of structures in
the hilum. d CT scan in a patient postright hepatectomy
depicting how posterolateral displacement of the hepatic
hilum due to left liver hypertrophy may lead to difficulty
in access to the portal structure and may require the use of
thoracoabdominal incision
at the base of segment IVb by dividing the reflection of Glisson’s capsule onto the gastrohepatic
ligament, a maneuver called “lowering the hilar
plate” (Fig. 19.3b). Left hepatic artery joins the
“portal diad” at the base of the umbilical fissure.
As the left hepatic duct runs in the umbilical fissure, it receives biliary ducts from segments II,
III, and IV. Often, the left duct in the umbilical
fissure is covered by a bridge of hepatic tissue
that crosses from the left lateral section to the
base of segment IV, and these need to be divided
to gain access to the biliary and vascular structures in the umbilical fissure.
196 V. Dudeja and Y. Fong
Operative Repair
Operative repair of outflow injuries (stricture
or fistula) to the remnant liver after major hepatectomy is not an easy undertaking. It is a difficult task being performed in a nonideal setting.
Postoperative adhesions and inflammation due
to biliary leak makes the access to a healthy
piece of duct for hepaticoenterostomy challenging. Furthermore, regeneration alters the normal
anatomic configuration of the portal structures
[9] and the access to the hepatic hilum is often
limited and critically dependent on the nature of
prior resection. As the liver regenerates and the
remnant expands to fill the space created by liver
resection, an unavoidable distortion of the hepato-duodenal ligament and hilar structure follows
[9, 10]. After a right hepatectomy, regeneration
and hypertrophy of left lobe leads to posterolateral and upward displacement of the hepatic
hilum. This may lead to difficulty in access to
the portal structure and may require the use of
thoracoabdominal incision (Fig. 19.3c and d).
On the other hand, compensatory hypertrophy of
right lobe after left hepatectomy leads to rotation
of the portal triad towards midline. Furthermore,
caudate hypertrophy would lead to anterior displacement of the hepato-duodenal ligament. This
puts hepatic hilum at a very superficial location
in harm’s way to an unwary operator. Thus, bile
duct repair after previous hepatic resection involves safe definition and isolation of a healthy
bile duct for anastomosis and construction of a
well-vascularized hepaticoenterostomy.
Given these changes in configuration of portal structure, as soon as we enter the abdomen,
we identify important landmarks that help in safe
conduct of the operation. After previous right
hepatectomy, we identify following structures.
(1) Remnant of the ligamentum teres is then followed to the base of umbilical fissure to define
the location of left hepatic artery. This is the
constant location of left hepatic artery, whether
it arises from common hepatic artery or from
left gastric artery in its variant configuration.
(2) Lesser omentum is opened early in the operation to identify the caudate lobe. Once identified,
a finger can be passed in front of the caudate to-
wards the foramen of Winslow to define the location of portal vein. (3) Inferior vena cava (IVC)
is identified next by performing a Kocher maneuver and mobilizing duodenum off IVC. Early
identification of IVC helps in dissection of liver
off vena cava and isolation of the hepatoduodenal ligament for the application of Pringle maneuver. In patients with prior left hepatectomy,
as mentioned before, the operator should be wary
of the unpredictably anterior location of the portal vasculature. We typically mobilize the liver
and perform the Kocher maneuver, thus identifying the IVC which can then followed caudally
to identify the portal vein from the right. Once
the liver is mobilized, cephalad retraction of the
undersurface of liver along the base of segment
IVb enhances optimal visualization of the hilar
structures. After the identification of the critical
structures, the attention can be focused on managing the bile duct pathology.
The tenets of operative repair of biliary injuries
are as follows: (1) identification of healthy bile
duct mucosa proximal to the site of obstruction,
(2) preparation of a segment of alimentary tract
(generally in the form of roux limb), and (3) creating a direct anastomosis between biliary and
jejunal mucosa. Detailed evaluation of preoperative imaging studies to comprehend the lay of the
land in terms of location of vascular anatomy and
determining the site of anastomosis as well as judicious use of preoperative biliary stents is critical to the success of this endeavor. If an injury is
discovered during the initial liver resection itself,
small injuries can be closed with interrupted 4-0
vicryl or other fine absorbable suture. In case of
large defects or loss of tissue, a hepatoenterostomy is imperative.
Repair of Injury to Right Liver Outflow
In patients with injury to right hepatic duct during conduct of a left hepatectomy, anastomosis
to the right hepatic ducts is necessary. Lowering
what is left of the hilar plate may demonstrate
the junction of right hepatic duct with the stump
of left hepatic duct forming the common hepatic
duct. If a stapler was used to divide the left hepat-
19719 Contralateral Bile Duct Injury During Hepatic Resection
Fig. 19.4 Approach to the right sectoral ducts for bypass.
a If the extrahepatic course of the right hepatic duct is
strictured then anastomosis with one of the sectoral ducts,
usually the anterior, is required. For this, a triangular piece
of liver tissue between the base of the gallbladder fossa
and the caudate process, which overlies the confluence of
the right anterior and posterior sectoral ducts to form the
right hepatic duct, is removed. b Once exposed, a ductotomy is made in the anterior sectoral duct and can be
ic duct in previous operation, then location of staples may help identify the left duct stump which
can be traced to the hepatic duct confluence. If
the extrahepatic course of the right hepatic duct
is not sufficient then exposure of the confluence
of the right anterior and posterior sectoral ducts
to form the right duct and anastomosis with one
of the sectoral ducts, usually the anterior, is a
fallback plan. For this, a triangular piece of liver
tissue between the base of the gallbladder fossa
and the caudate process, which overlies the confluence of the right anterior and posterior sectoral
ducts to form the right hepatic duct, is removed
(Fig. 19.4a and b). This tends to be a little bloody
and patience is paramount. Once exposed, a ductotomy is made in the anterior sectoral duct and
carried onto the stump of right hepatic duct and
a wide anastomosis fashioned between the right
duct and the Roux limb of jejunum. If the confluence of the right anterior and posterior ducts
is destroyed, then this anastomosis would not
drain the right posterior sector and a separate
anastomosis to the right posterior duct needs to
be carried out.
carried onto the stump of right hepatic duct and a wide
anastomosis between the right duct and the Roux limb of
jejunum can be fashioned. c Exposure of the segment III
duct for bypass can be achieved by dividing the liver tissue between segment IV and left lateral segment. Liver
is split just to the left of the falciform ligament, and the
tissue is divided superiorly until the segment III duct is
reached. Duct is opened longitudinally, and anastomosis
with Roux limb constructed
Repair of Injury to Left Liver Outflow
In patients with left duct injury after a right
hepatectomy, anastomosis to the left hepatic
duct in its transverse location at the base of segment IVb is the preferred method of biliary bypass. Hypertrophy of left liver generally places
the hilum posteriorly and laterally and a good
access, which is critical to the success of this
procedure, generally requires a right lateral thoracic extension of the incision. Anterocephalad
traction on the falciform ligament and elevation
and retraction of segment IVb with the help of
a curved retractor expose the transverse course
of left hepatic duct. Opening the bridge of liver
tissue between segment IVb and II allows access to the base of the left portal pedicle. By
dissecting between Glisson’s capsule and the
peritoneum encasing the portal triad at the base
of segment IV, the hilar plate is lowered. At this
location, the portal vein is more superficial to
bile duct. Deepening the plane of dissection
moves the portal structures away from the front
of bile duct. If a good length of left duct can be
exposed, it is incised longitudinally and a sideto-side single-layer interrupted mucosa to mucosa anastomosis is carried out between the duct
and the Roux limb.
198 V. Dudeja and Y. Fong
If the transverse portion of the left duct is not
suitable for drainage, a segment III bypass can be
performed. For this, ligament teres is retracted
caudally and to patient’s right. The peritoneum
of its upper surface on the left side is divided,
and the tissue between the ligamentum teres and
segment III is divided between ligatures. This exposes the segment III duct. Sometimes, a wedge
of tissue over the duct needs to be resected to expose the duct properly; this also broadens the area
where the Roux limb can sit (Fig. 19.4c and d).
Prevention of Contralateral Bile Duct Injury
Attention to Variation in Biliary
Detailed evaluation of preoperative imaging can
alert the surgeon to variation in biliary anatomy.
As more than a third of patients are expected to
have variant biliary anatomy, the abnormal anatomy should be actively sought for. In cases with
variant anatomy, the plane of transection can be
modified to protect the contralateral bile duct.
Intrahepatic Control of Biliary Radicals
Biliary radicals can be controlled extrahepatically or intrahepatically. In the extrahepatic
method, the bile duct is dissected and divided
extrahepatically. This method is associated with
higher risk of biliary injury, especially on right
side where the anatomic variations of the sectoral
duct drainage are common. We prefer intrahepatic transection of biliary radicals when possible.
Portal vein and the hepatic artery may be divided
extrahepatically, thus demarcating the liver. The
bile duct is not divided extrahepatically and biliary radicals encountered in the plane of transection are divided. We find this technique safer as
the division of biliary radicals is being performed
away from the contralateral outflow. However,
intrahepatic ligation of biliary radicals may not
be feasible for hilar cholangiocarcinoma as well
as tumors that are close to the hilum. In left-sided
resections, we find extrahepatic ligation of bile
duct at the base of umbilical fissure equally safe
due to long extrahepatic course of left pedicle.
Tumor Close to the Hilum
If the tumor is close to the hilum and the contralateral outflow is at risk, we avoid using stapler
for biliary division. In such cases, the bile duct
is sharply divided with a knife and specimen removed. This protects the contralateral bile duct
and provides a little extra length for anastomosis
if a hepaticoenterostomy is needed.
Outcomes
Given the low incidence of posthepatectomy
contralateral bile duct injury, data on long-term
outcomes after repair of such injuries are lacking.
However, some inferences can be gleaned from
outcome data of benign postcholecystectomy
biliary stricture repair. Data on outcomes of hepatico-jejunostomy to right-sided bile duct system are limited. However, it appears that in experienced hands, good long-term outcomes and
low rate of restricture can be achieved. In a small
series of 23 patients with a limited follow up of
median 3 years (8 months–7 years), no restructuring was reported [11]. Similarly, in experienced
hands, biliary bypass to the transverse segment of
left hepatic duct seems to be durable as well. The
group from Mayo has reported excellent shortterm outcomes with biliary–enteric anastomosis
to extrahepatic transverse segment of left hepatic
duct [12]. Likewise, in a study from Poland
[13], at a median follow-up of 59 months (range
6–102 months), a low restricture rate of 6 % was
observed after reconstruction of complex high
biliary stricture using this approach. Data suggest that timing of repair may also affect outcomes with repairs conducted in the intermediate
period (> 72 h but < 6 weeks) were significantly
associated with more strictures [14]. However,
it is important to execute the repair in a timely
fashion and to take steps to protect liver func-
19919 Contralateral Bile Duct Injury During Hepatic Resection
tion and prevent obstruction-induced cirrhosis
and portal hypertension, as mortality with these
procedures is markedly influenced by preoperative liver function and the presence or absence of
portal hypertension [15].
Five Key Points to Avoid Contralateral Bile Duct Injury
1. Preoperative image should be evaluated criti-
cally to alert the surgeon to patient-specific
variation in biliary anatomy.
In patients with variant anatomy of the biliary
2.
ductal system, the plane of transection
should
be modified to protect the contralateral bile
duct.
When feasible, the bile duct should be con-
3.
trolled intrahepatically, as this allows bile
duct division away from the contralateral outflow.
In left-sided resections, the
4.
bile duct should be
ligated at the base of umbilical fissure away
from outflow of right side.
If the tumor is close
5.
to the hilum and the contralateral outflow is at risk, avoiding the use of
a stapler for biliary division can help protect
the contralateral bile duct from injury.
Five Key Points to Diagnose and Treat Contralateral Bile Duct Injury
1. In case of contralateral bile duct injury, control of sepsis with adequate drainage of any
intraabdominal collection, antibiotics, and relief of obstruction are the priorities.
2. Biliary system of the remnant should be adequately drained to prevent adverse consequences of biliary obstruction. Drainage is
typically obtained through percutaneous transhepatic route.
3. MRCP and drain study through percutaneously placed transhepatic catheter help define the
anatomy and facilitate preoperative planning.
4. Due to remnant hypertrophy, the normal anatomic configuration of the portal structures is
altered, and the access to the hepatic hilum is
often limited and critically dependent on the
nature of prior resection.
5.
The tenets of operative repair of biliary in-
juries are as follows: (1) identification
healthy bile duct mucosa proximal to the site
of obstruction, (2) preparation of a segment
of alimentary tract (generally in the form of
Roux limb), and (3) creating a direct anastomosis between biliary and jejunal mucosa.
References
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Jong KP, Slooff MJ, Porte RJ. Risk factors for central
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Massive Intraoperative Hemorrhage During Hepato-Biliary and Pancreatic Surgery
Vikas Dudeja and William R. Jarnagin
20
Introduction
Historically, progress in liver surgery was hindered by absence of surface landmarks, incomplete understanding of the well-defined internal
anatomy, and the lack of ability to control bleeding from the liver tissue and associated vessels.
For many years, major hepatic resection was
complicated by large volume blood losses and
its attendant mortality and morbidity. Only with
a better understanding of liver’s segmental anatomy, coupled with refinement in operative technique and advancements in intra- and peri-operative management, has liver surgery emerged
as a safe and effective therapeutic option. Even
with current progress and increased exposure to
hepatic surgery in surgical training, expertise in
major liver surgery requires focused training and
is largely limited to specialized centers.
W. R. Jarnagin () · V. Dudeja
Department of Surgery, Memorial Sloan-Kettering
Cancer Center, 1275 York Avenue, C-887, New York,
NY 10065, USA
e-mail: jarnagiw@mskcc.org
V. Dudeja
e-mail: dudejav@mskcc.org
Hemorrhage During Liver Surgery
Magnitude of Problem
Risk of hemorrhage remains a major concern
during liver resection. In a review of major liver
resections, excluding wedge resections, performed between 1991 and 1997 at Memorial
Sloan-Kettering Cancer Center [1], mean blood
loss was 848 ± 972 ml and ranged from 40 to
9000 ml. Over 13 % of patients experienced intra-operative blood loss of more than a quarter of
their estimated blood volume [1]. Even in a more
contemporary series of major hepatectomies,
median blood loss of 700 with an inter-quartile
range of 400–1050 is reported [2]. Excessive
bleeding has been shown to correlate with postoperative morbidity. 30–47 % of patients are reported to receive allogenic blood components
during or within 24 h of major hepatectomy [1,
2]. Allogenic blood transfusion in itself is not a
benign intervention. Despite markedly increased
safety of national blood supply, transmission of
various viral and bacterial pathogens is a persistent concern [3]. Furthermore, immunomodulatory effects of blood transfusion may lead to increased predisposition to infection and reduction
in cancer disease-free survival [4, 5]. Though
hemorrhage can occur during liver transection,
as well as from and during control of hilar vessels, injury to hepatic vein and retro-hepatic vena
cava is the most common cause of major intraoperative hemorrhage. Precise knowledge of liver
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_20,
© Springer Science+Business Media New York 2015
201
202 V. Dudeja and W. R. Jarnagin
anatomy is the key to successful and safe hepatic
resection.
Hepatic Vascular Anatomy
Despite lack of any corresponding surface landmark, liver has an intricate, intrinsic, functional,
and segmental anatomy. Liver is divided into four
sectors and eight segments. Each segment is supplied by an independent portal pedicle containing
triad of branch of hepatic artery, portal vein (PV),
and bile duct. The sectors are separated by portal
scissura which are defined by location of hepatic
veins. Thus, the intrahepatic vascular anatomy
forms the basis of segmental anatomy of the liver.
a. Hepatic Venous Anatomy: The liver has
three major veins, which drain from the posterior surface directly into the IVC. These veins
divide the liver into four scissura, sectors, or
sections. The right vein runs in the right scissura and divides the right liver into anterior
and posterior sector. It has a short extrahepatic
course of about 1 cm. The left hepatic vein
runs in the left scissura and form the division
between segment 2 and 3. The middle hepatic
vein runs in the portal scissura and forms the
division between left and right liver. Generally, the left and the middle hepatic veins join
intrahepatically and enter the retro-hepatic
IVC as a single vessel. Multiple small hepatic
veins drain directly from the posterior sector
of right liver and the caudate lobe into the
IVC. These veins appear small but should be
divided carefully between ligatures or clips as
they can cause troublesome bleeding impeding vision. The umbilical fissure, the only surface marking of significance, contains the left
portal pedicle but no hepatic vein.
b. Hepatic arterial Anatomy: Hepatic artery
flow provides oxygenated flow to the liver and
constitutes 25 % of total blood supply, the remaining 75 % being supplied by portal venous
flow. Anatomical variations are very common
in hepatic arterial anatomy, and the common
description of hepatic arterial anatomy is present only 60 % of the time. In this description,
the common hepatic artery, which arises from
celiac trunk and forms proper hepatic artery
after giving rise to the gastroduodenal artery,
divides at the hilum to give rise to right and
left hepatic artery. The right hepatic artery
courses between common hepatic duct and
PV to supply right liver. The left hepatic artery joins the left PV and bile duct at the base
of umbilical fissure to supply segments 2, 3,
and 4. About 40 % of patients have variant
patic anatomy. A replaced or accessory right
hepatic artery arises from the superior mesenteric artery (SMA) near its origin and course
posteriorly or through the head of the pancreas
and is present ~
or accessory left
20 % of the time. A replaced
hepatic artery arises from the
left gastric artery and courses transversely towards the base of the umbilical fissure in the
lesser omentum 12–15
c. Hepatic Portal V
% of the time.
enous Anatomy: The superior mesenteric vein (SMV) and splenic vein
join behind the neck of the pancreas to form
PV which runs in the free edge of hepato-duodenal ligament en route to liver. This location
of PV makes the Pringle maneuver feasible.
At the hilum, the PV divides into right PV,
which has a short extrahepatic course, and left
PV, which has along extrahepatic course of
cm (Fig. 20. 1a).
3–4
The right PV, after entering the liver substance, divides into anterior
and posterior sectoral branches (Fig.
These sectoral
branches can sometimes arise
20.1a).
directly from the main PV extrahepatically.
The left PV runs transversely along the base
of segment 4b before turning anteriorly and
caudally in the umbilical fissure where it gives
branches to the segment 2 and 3 and recurrent branches to segment 4 (Fig. 20.1a). The
hepatic portal venous anatomy has much less
anatomical
variation when compared with
hepatic arterial or biliary anatomy. The most
common variations include portal trifurcation (~
12–20 %), where the right anterior,
right posterior, and left portal branches share
a comm
on origin (Fig.
posterior PV
of main PV (~
branch arising as a direct branch
9 %) (Fig. 20.1c–
20.1b), and the right
e) [6–8]. In the
latter situation, the left PV and right anterior
PV share a common trunk (Fig.
20.1c–e
he-
).
20320 Massive Intraoperative Hemorrhage During Hepato-Biliary and Pancreatic Surgery
Fig. 20.1 Standard and variant portal venous anatomy. a
In standard portal venous anatomy, superior mesenteric
vein ( SMV) and splenic vein ( SV) join behind the neck
of the pancreas to form portal vein ( PV). At the hilum,
the PV divides into right portal vein ( RPV) and left portal
vein ( LPV). RPV after entering the liver substance divides
into right posterior sectoral ( RPS) and right anterior sec-
toral ( RAS) branches. The LPV runs transversely along
the base of segment 4b before turning anteriorly and caudally in the umbilical fissure where it gives branches to
the segments II, III, Iva, and IVb, much less anatomical
variation when compared with hepatic arterial or biliary
anatomy. b The most common variations include portal
trifurcation (~ 12–20 %), where RPS, RAS, and LPV share
a common origin ( arrow). c Second most common vari-
ant is where RPS branch arises as a direct branch of PV
(~ 9 %). In the latter situation, the LPV and right anterior
PV share a common trunk ( bracket). d CT scan of a pa-
tient with the separate origin of RPS from PV. e Intraoperative image of the same patient. Notice that RAS shares
a common origin with LPV