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Preoperative Assessment of Vascular Anatomy Around the Stomach by 3D Imaging Using MDCT Before Laparoscopy-Assisted Gastrectomy

¹ Department of Radiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka 569-8686, Japan.
² Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki City, Osaka 569-8686, Japan.

View larger version (89K): [in a new window]   Fig. 1. —Michels classification [6] shows branching patterns of left gastric, hepatic, and splenic arteries. CHA = common hepatic artery, LGA = left gastric artery, SA = splenic artery, SMA = superior mesenteric artery.

View larger version (83K): [in a new window]   Fig. 2A. —CT angiographic reconstruction using volume rendering. CHA = common hepatic artery, LGA = left gastric artery, SA = splenic artery, SMA = superior mesenteric artery. In 55-year-old woman with gastric cancer, image clearly shows LGA originating from celiac trunk (type I, hepatosplenogastric trunk [6]).

View larger version (117K): [in a new window]   Fig. 2B. —CT angiographic reconstruction using volume rendering. CHA = common hepatic artery, LGA = left gastric artery, SA = splenic artery, SMA = superior mesenteric artery. In 67-year-old woman with gastric cancer, image clearly shows LGA originating from aorta (type II, hepatosplenogastric trunk [6]).

View larger version (112K): [in a new window]   Fig. 2C. —CT angiographic reconstruction using volume rendering. CHA = common hepatic artery, LGA = left gastric artery, SA = splenic artery, SMA = superior mesenteric artery. In 67-year-old man with gastric cancer, image clearly shows LGA originating from SA (type II, hepatosplenogastric trunk [6]).

View larger version (100K): [in a new window]   Fig. 3A. —CT angiographic reconstruction using volume rendering. In 65-year-old man with gastric cancer, image clearly shows right gastric artery (RGA) originating from left hepatic artery (LHA).

View larger version (97K): [in a new window]   Fig. 3B. —CT angiographic reconstruction using volume rendering. In 55-year-old woman with gastric cancer, image clearly shows RGA originating from gastroduodenal artery (GDA).

View larger version (78K): [in a new window]   Fig. 4A. —Replaced left hepatic artery (LHA) in 55-year-old woman with gastric cancer. CT angiographic reconstruction with volume rendering clearly shows replaced LHA originating from left gastric artery (LGA). On basis of this finding, plan is devised before surgery to preserve replaced LHA and to ligate LGA distal to replaced LHA-originating point (red line).

View larger version (139K): [in a new window]   Fig. 4B. —Replaced left hepatic artery (LHA) in 55-year-old woman with gastric cancer. Photograph of intraoperative view shows replaced LHA originating from LGA. Red line represents LGA distal to replaced LHA-originating point.

View larger version (84K): [in a new window]   Fig. 5. —Diagram shows patterns of inflow of left gastric coronary vein. PHA = proper hepatic artery, CHA = common hepatic artery, SA = splenic artery, SV = splenic vein, SMV = superior mesenteric vein, PV = portal vein.

View larger version (118K): [in a new window]   Fig. 6A. —Left gastric coronary vein (LCV) joining portal vein in 55-year-old woman with gastric cancer. LGA = left gastric artery. CT angiographic reconstruction using volume rendering clearly shows LCV joining portal vein after running along dorsal side of common hepatic artery (CHA), classified as type 3B (Fig. 5).

View larger version (119K): [in a new window]   Fig. 6B. —Left gastric coronary vein (LCV) joining portal vein in 55-year-old woman with gastric cancer. LGA = left gastric artery. Photograph of intraoperative view shows that ligation of LCV joining portal vein after running along dorsal side of CHA is performed first, and then excision of lymph nodes in anterosuperior region of common hepatic artery (Japanese classification 8a [7]) is performed.

View larger version (91K): [in a new window]   Fig. 7A. —Diagrams of approaches to treatment of origin of right gastric artery (RGA) after treatment of area facing greater omentum. GDA = gastroduodenal artery. When RGA originates from proper, left, or right hepatic artery (RHA), first portion of duodenum is carefully dissected. Then origin of RGA is identified and artery is ligated.

View larger version (100K): [in a new window]   Fig. 7B. —Diagrams of approaches to treatment of origin of right gastric artery (RGA) after treatment of area facing greater omentum. GDA = gastroduodenal artery. When RGA originates from GDA, stomach is first everted, then origin of RGA is identified, and artery is ligated. CHA = common hepatic artery.

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