We describe a case report of multiple arterial variations of internal organs of upper abdominal cavity in a cadaver of 63-year-old female. There were several developmental variations of the vascular supply of the stomach, pancreas, spleen, and liver. There were several accessory arteries: left gastric, left hepatic, and posterior gastric artery as well as several arteries that had abnormal origin. The variations were discovered during macroscopical dissection at the department of human anatomy. It should be noted that multiple developmental variation can be common in clinical practice and clinicians should be aware of them during diagnostic and interventional procedures.
The upper part of abdominal cavity is limited by the diaphragm from the top, from the sides by lateral abdominal walls and from the inferior part by the transverse colon and its mesentery. This anatomical region is particularly important for hepatopancreatobiliary, vascular, and transplant surgeons as it is rich in anatomical variations that can compromise the procedure. The vascularization of upper abdominal cavity’ organs has been studied abundantly [
The celiac trunk provides the vascular supply of the upper abdominal organs. Uflacker classified the celiac trunk into 8 types: classic coeliac trunk, hepatosplenic trunk, hepatogastric trunk, hepatosplenicmesenteric trunk, gastrosplenic trunk, coeliac-mesenteric trunk, and no coeliac trunk [
Detailed knowledge of topographical and morphological as well as the functional possibilities of the anatomical regional and its surrounding structures including collateral paths of vascularization is essential for surgical procedures [
During the macroscopical dissection of a 63-year-old female cadaver we determined several anomalies of the vascularization of upper abdominal cavity organs.
The celiac trunk branched into two vessels: the left gastric artery and a hepatosplenic trunk, which further divided into splenic and common hepatic arteries (Figure
The branches of the celiac trunk. Macrospecimen (female, 63 years old). 1: celiac trunk, 2: common hepatic artery, 3: splenic artery, 4: left gastric artery, 5: accessory left gastric artery, 6: posterior gastric artery, 7: left gastroepiploic artery 8: splenic vein, 9: spleen, 10: pancreas, 11: caudate lobe of the liver, and 12: stomach.
The splenic artery in its proximal part had a sinuous trajectory. In the medium part of the vessel the artery had a curve with the base situated superiorly which then continued in a straight manner in the prehilar area. In the hilar region the splenic artery branches into three branches of the first order, two of which were terminal and entered directly into splenic parenchyma.
The superior splenic branch of the first order divided into two second order branches. From the superior second order branch a superior polar branch took origin (Figure
The branches of splenic artery. Macrospecimen (female, 63 years old). 1: splenic artery, 2: splenic vein, 3: posterior gastric artery, 4: splenic arteries of the first order 5: splenic arteries of the second order, 6: superior polar artery 7: left gastroepiploic artery 8: spleen, 9: stomach, and 10: pancreas.
We should also mention the presence of two posterior gastric arteries, which also branched from the splenic artery. The first posterior gastric artery took origin from the site, where the splenic artery branched from the hepatosplenic trunk and passed to the fundus of the stomach. The second posterior gastric artery is a more common variant that took origin from the second branch of the first order (Figures
The common hepatic artery passed near the right side of the caudate lobe of the liver and at the level of the pancreas head (after giving a gastroduodenal branch) continued into proper hepatic artery which branched into left hepatic arteries and a larger right hepatic artery (Figure
Liver blood supply. Macrospecimen (female, 63-year-old). 1 – common hepatic artery, 2 – proper hepatic artery, 3 – gastroduodenal artery, 4 – left hepatic artery, 5 – right hepatic artery, 6 – accessory left hepatic artery, 7 – right gastroepiploic artery, 8 – superior posterior pancreaticoduodenal artery, 9 – superior duodenal artery, 10 – right gastric artery, 11 – the branch of the superior anterior pancreaticoduodenal artery, 12 – portal vein, 13 – liver, 14 – common bile duct, 15 – gall bladder, 16 – duodenum, 17 – pancreas, 18 – intermediate hepatic artery.
A rare variation is also the presence of an accessory left hepatic artery, which began from the proper hepatic artery and supplied the left and the caudate lobes of the liver. From the proper hepatic artery took origin the superior duodenal artery that passed to the bulb of the duodenum. The proper hepatic artery then gave off its terminal branches: the right and left hepatic arteries. The intermediate hepatic artery branched from the right hepatic artery and passed to the quadrate lobe of the liver (Figure
The cystic artery was situated behind the cystic duct, outside the Calot triangle
Cystic artery. Macrospecimen (female, 63 years old). 1: common hepatic artery, 2: proper hepatic artery, 3: gastroduodenal artery, 4: left hepatic artery, 5: right hepatic artery, 6: accessory left hepatic artery, 7: intermediate hepatic artery, 8: superior posterior pancreaticoduodenal artery, 9: superior duodenal artery, 10: right gastric artery, 11: right gastroepiploic artery, 12: liver, 13: duodenum, 14: cystic artery, 15: hepatic duct, 16: cystic duct, and 17: common bile duct.
The gastroduodenal artery gave two branches: the posterior superior pancreaticoduodenal artery and the right gastroepiploic artery. From the right gastroepiploic artery branched the superior anterior pancreaticoduodenal artery and a short branch to the common bile duct (Figures
The branches of pancreaticoduodenal artery. Macrospecimen (female, 63 years old). 1: gastroduodenal artery, 2: right gastroepiploic artery, 3: superior posterior pancreaticoduodenal artery, 4: superior duodenal artery, 5: right gastric artery, 6: right gastroepiploic artery, 7: proper hepatic artery, 8: common hepatic artery, 9: superior anterior pancreaticoduodenal artery, 10: pancreas, 11: liver, 12: stomach, and 13: common bile duct.
A: abdominal aorta; 1: celiac trunk, 2: left gastric artery, 3: accessory left gastric artery, 4: second left gastroepiploic artery, 5: second posterior gastric artery, 6: terminal branches of the splenic arteries, 7: splenic arteries, 8: left gastroepiploic artery, 9: posterior gastric artery, 10: right gastroepiploic artery, 11: superior anterior pancreaticoduodenal artery, 12: gastroduodenal artery, 13: posterior superior pancreaticoduodenal artery, 14: right gastric artery, 15: superior duodenal artery, 16: left hepatic artery, 17: accessory left hepatic artery, 18: intermediate hepatic artery, 19: cystic artery, 20: right hepatic artery, 21: proper hepatic artery, and 22: common hepatic artery.
Based on the current data from the literature there are multiple types of liver and gallbladder vascularization. Watson and Harper (2015) report that the hepatic artery can have variable origin (10 types based on Michels classification, 1955). There are often accessory left and right hepatic arteries (10-20% of cases) [
The trifurcation of the hepatic artery can be encountered in approximately 3.3% of cases [
De Martino RR and coworkers consider that the anomalies of the splenic artery can be part of the celiac trunk anomalies. The vessel may start from the aorta with one or two branches. It also may take origin from left gastric, middle colic, or left hepatic artery [
The vascularization of the stomach is also highly variable. The left gastric artery can take origin from aorta, celiac trunk, or accessory left hepatic artery (1-16%) and left hepatic artery (10%) [
Accessory gastric arteries are often present and most commonly originates from hepatic vessels (21.2%) [
The posterior gastric artery is a branch of the splenic artery and supplies the posterior stomach wall. For the first time it was mentioned by Walther in 1729 and after that rediscovered by Suzuki and coworkers in 1978. This artery can be found in 4 to 100%. Nevertheless, the authors report that it is present in 37.5-48% of cases [
Finally, there are incidental findings that developmental variations of vascular supply are linked to anomalies of the organs shape [
During the macroscopical dissection, we determined the accessory arteries of the upper abdominal cavity: left gastric, left hepatic, and two posterior gastric arteries, which have clinical importance in surgery. Textbook anatomy gives an overview of the most common type of developmental variation. Nevertheless, during interventional procedures one may encounter cases that are more complex. The presence of accessory gastric arteries may complicate gastric resections. Hepatic vascular anatomy is important during hepatic transplant and resections in case of pathological processes (for example, tumors). Finally, lesions to the posterior gastric arteries can lead to the necrosis of the posterior part of the stomach with drastic complications. Modern procedures in hepatopancreatobiliary and vascular surgery still depend on the knowledge of the regional anatomy and this case demonstrates there is much that can be learned from cadaver dissections.
The authors declare that there are no conflicts of interest regarding the publication of this paper.