J Hepatobiliary Pancreat Surg (2002) 9:531533

Topics: Laparoscopic HBP surgery Surgical anatomy of hepatoduodenal ligament and hepatic hilus
Eldar M. Gadz ijev
Department of Surgery, Teaching Hospital Maribor, Ljubljanska 5, 2000 Maribor, Slovenia

Abstract The anatomical situation and variations of structures in the hepatoduodenal ligament and hepatic hilus are a legacy of their embryological development. The vascular, biliary, and lymphatic structures contribute to the functioning of blood and bile ow as well as lymph drainage of the liver. Connective tissue, fatty tissue, and the peritoneal sheet are enveloping underlying structures. Their position, shape, and relation to neighboring structures inuence the situation during operative procedures. The cystic artery origin is variable, as is the number; and its recognition is important for safe cholecystectomy. Venous drainage of the gallbladder goes into the portal system of adjacent segments 4 and 5 and inuences the spread of gallbladder pathology. There are some surgically important variations in the course and distribution of bile ducts and arteries in the hepatoduodenal ligament. The biliary anatomical variations signicantly inuence the incidence of bile ducts injuries during laparoscopic cholecystectomy. The arterial supply of extrahepatic bile ducts is delicate and variable and should be considered when trying to prevent ischemic injuries to the bile ducts. Inammation and the combination of inammation and anatomical variation are thought to contribute to a dangerous situation in regard to eventual injury to the bile ducts and vascular structures during operative procedures. This paper explores these questions. Key words Hepatoduodenal ligament Vascular structures Biliary system Anatomical variations Surgery

vascular or biliary system in the hepatoduodenal ligament and porta hepatis should be considered a serious problem that must be avoided. Surgical skill, proper surgical technique, and suitable operating tools permit safe laparoscopic surgery; and good knowledge of anatomy is essential. The hepatoduodenal ligament and hepatic hilus contain extrahepatic bile ducts along with gallbladder, hepatic artery branches, portal vein, and lymphatic, soft, and fatty tissue wrapped in a serous covering. The ductal system of the liver, gallbladder, and pancreas develops from budding of endodermal diverticula of the duodenum (abdominal foregut) into the septum transversum. The latter contributes to formation of the serous covering for the structures attaching the liver to the stomach and duodenum (the lesser omentum and hepatoduodenal ligament). The growth and consequent rotation of the duodenum cause the ventral pancreatic bud and bile duct to migrate to the dorsal aspect of the duodenum.

Discussion Anatomy of the gallbladder The gallbladder and cystic duct develop from a cystic diverticulum. There are variations of the shape and position of the gallbladder. It can be double, have a septum, be situated deep in the liver parenchyma, or have its own mesenterium.1 The gallbladder can even be located on the left side, but its anatomical variations seldom impede safe cholecystectomy if anatomical structures are recognized. Acute inammation can cause important changes in anatomical relations. The cystic duct has a distinctive form and shape. Its fusion with the common bile duct occurs with different distances, positions, and forms. It can enter the extrahepatic bile duct from the right side, behind, or the left

Introduction The hepatoduodenal ligament, porta hepatis, and gallbladder are the sites addressed by laparoscopic cholecystectomy. This procedure is performed with the intention to cure cholelithiasis, a potentially disturbing, although benign, pathology. Therefore, injuries to the

Offprint requests to: E.M. Gadz ijev Received: July 9, 2002 / Accepted: July 10, 2002

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E.M. Gadz ijev: Surgical anatomy

side; or it can accompany the extrahepatic bile duct for some distance, sometimes even close to the ampulla of Vater. Based on our experience and others (Wiechel), the cystic duct enters the common bile duct most often from the posterior side. The cystic artery is varied in its number, origin, and course. There can be a single cystic artery originating from the right hepatic artery or the right anterior sectional artery, the right posterior hepatic artery, the replacing or accessory right hepatic artery, or the arteries for segments 5, 6, and 8. There can also be two cystic arteries, both originating from the right hepatic artery or the right anterior sectional artery, or one may originate from the right hepatic artery and another from the right anterior sectional artery, or one from the right hepatic artery and the other from the left hepatic artery. Exceptionally, the origin of the cystic artery can be from more distant sources, such as the common hepatic artery, proper hepatic artery, or even the gastroduodenal and right gastric artery. Venous drainage of the gallbladder is into the portal system of adjacent liver segments 4 and 5. This fact explains the spread of pathology from the gallbladder into the liver parenchyma. Bile ducts The course and conuence of the extrahepatic bile ducts have several key variations, and surgeons should be aware of them. For laparoscopic and classic cholecystectomy, important variations of the bile ducts that may be encountered are an extremely low common conuence with the cystic duct entering the right hepatic duct, no right hepatic duct present and the cystic duct entering the right anterior or right posterior sectional duct, or segmental ducts from segment 5 or 6 entering the common hepatic duct separately. Arteries During open surgery the hepatic artery and its branches can be easily palpated. This is not so during laparoscopic procedures. The normal course and branching of the hepatic artery is such that the right hepatic artery crosses the common hepatic duct (CHD) from behind; only in 20% of cases does it appear in front of the CHD, causing some topographical changes in the triangle of Calot that should be recognized. The artery for the right liver runs along the right lateral border of the hepatoduodenal ligament mostly when it originates from the superior mesenteric artery. We call such an artery a replacing right hepatic artery when it nourishes the whole right hemiliver or a partially replacing artery when it nourishes only part of the right hemiliver. Such an artery can also be an accessory if it is

linked by the right hepatic artery arising from the proper hepatic artery, which originates from the celiac artery. Sometimes a right hepatic artery from the original source (celiac artery) can run along the right lateral border of the hepatoduodenal ligament when it crosses the portal vein and common bile duct from behind.2 For injuries that follow laparoscopic cholecystectomy, the delicate blood supply to the bile ducts is of great importance. The extrahepatic bile ducts are supplied by as many as seven arteries, and we nd three anastomotic patterns: a network, a longitudinal chain, and an arterial circle. If we divide the extrahepatic bile ducts into four portions in consideration of the blood supply, we get an interesting situation: The gallbladder and cystic duct have a rich network, but the right and left hepatic ducts with conuence have a sparse network of arteries that also nourish segment 1. The CHD and the supraduodenal and retroduodenal portions of the common bile duct (CBD) have a sparse longitudinal anastomotic chain subject to injury. In contrast, the pancreatic and intraductal portions of the CBD has an abundant network of arteries.3 The longitudinal anastomotic chain of blood supply to the CHD and CBD may have a variety of patterns. There can be a so-called axial type, with one or two arches of longitudinally running arteries supplying the CHD and CBD. These ducts can have a single ladder of arteries from the left side or a double ladder when arteries originate also from sectional hepatic arteries and the anterosuperior pancreatoduodenal artery. A mixed type of blood supply is present when there is a laddertype supply from the left side and an arterial arch from the right. Another mixed type is present when there are two arterial arches and a left-side ladder-type blood supply to the bile ducts.4 The arterial supply of extrahepatic bile ducts should always be considered during biliary surgery. Portal vein The portal vein is hidden in the hepatoduodenal ligament behind the extrahepatic bile ducts and hepatic artery. It is surrounded by a richly lymphatic, soft tissue, and serous covering. Important changes in the anatomical situation are encountered after injury to the portal vein, as a consequence of portal obstruction after thrombosis, or with cirrhosis accompanied by portal hypertension, when collateral veins encircle bile ducts and bulge into the soft tissue of the hepatoduodenal ligament. Portal vein anatomical variations such as portal trifurcation or quadrifurcation (where in both cases the right main portal branch is missing) can be found in the hepatic hilus. This, however, has no impact on laparoscopic cholecystectomy and is more important during liver resections.

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Lymphatics There is a network of lymphatic vessels and nodes in the hepatoduodenal ligament that drain the liver and gallbladder. Typical nodes are the hilar node, cystic node, pericholedochal node, retroportal node, foramen of Winslow node, superior retropancreatoduodenal node, and posterior pancreatoduodenal node.5 Following inammation or biliary obstruction, lymphatic nodes and vessels enlarge and can cause some confusion during laparoscopic cholecystectomy. Fibrotic envelope Fibrotic tissue forms a brotic envelope and hilar plate that separate the hilar structures from liver tissue. This envelope is important during dissection and acts as protection for structures of the hepatoduodenal ligament and hepatic hilus.

anatomical variations. They should also be aware of structures that might run along the right margin of the hepatoduodenal ligament and take into consideration the delicacy of the bile system blood supply. Most problems arise when the anatomical situation is altered. Such change may occur because of inammation or some other pathology (e.g., a tumor) and are even more probable when inammation is combined with anatomical variations in the course of structures associated with the hepatoduodenal ligament and hepatic hilus.

References
1. Blumgart LH (1988) Surgery of the liver and biliary tract. Churchill Livingstone, Edinburgh 2. Wiechel KL (1996) Biliary anatomy imaging and surgery: problems, possibilities, pitfalls and risks. Endoscopic Rev 1:320 3. Weinglein AH (1996) Variations and topography of the arteries in the lesser omentum in humans. Clin Anat 9:143150 4. Chen WJ, Ying DJ, Liu ZJ, He ZP (1999) Analysis of the arterial supply of the extrahepatic bile ducts and its clinical signicance. Clin Anat 12:245249 5. Rath AM, Zhang J, Bourdlat D, Chevrel JP (1993) Arterial vascularisation of the extrahepatic biliary tract. Surg Radiol Anat 15:105111 6. Kurosaki I, Tsukada K, Hatakeyama K, Muto T (1996) The mode of lymphatic spread in carcinoma of the bile duct. Am J Surg 172:239243

Conclusions Although most surgeons are familiar with this material, more extensive knowledge of the surgical anatomy can have a signicant impact on decreasing complications and morbidity during biliary surgery. Surgeons should be aware that structures in Calots triangle may have