Aberrant left hepatic artery originating from the left gastric artery identified during gastrectomy: a case report

Abstract

Background

Variations in hepatic arterial anatomy are clinically significant in upper abdominal surgery. A left hepatic artery (LHA) arising from the left gastric artery (LGA) is a recognized variant occurring in 6–21% of cases, but a large-caliber, dominant LHA is rare and has important implications during gastrectomy.

Case presentation

A 58-year-old man of Azerbaijani ethnicity with gastric cancer, after four cycles of chemotherapy, underwent gastrectomy with D2 + lymph node dissection. During mobilization of the gastrohepatic ligament, a large aberrant LHA was discovered intraoperatively. The vessel originated from the LGA, coursed parallel to the superior margin of the left hepatic lobe and entered the hepatic hilum as an independent trunk. Preoperative contrast-enhanced computed tomography (CT) had demonstrated this anomalous artery. The vessel measured approximately 15 mm in diameter, indicating dominant arterial supply. The artery was preserved, and the procedure was completed uneventfully.

Conclusion

A dominant aberrant LHA originating from the LGA is uncommon but clinically significant. Recognition of such variants—preferably through preoperative imaging—helps avoid inadvertent injury during gastrectomy.

Introduction

Variation of the hepatic arterial anatomy is of great practical importance when performing open and laparoscopic operations on the gallbladder, extrahepatic bile ducts, liver, pancreas, stomach, and duodenum, as well as during liver transplantation, endovascular radiological interventions, and intraoperative or percutaneous placement of implantable infusion systems for regional chemotherapy [1]

The classical arterial pattern, in which the common hepatic artery (CHA) arises from the celiac trunk, gives off the gastroduodenal artery (GDA), and then continues as the intrinsic hepatic artery (IHA) dividing into the right hepatic artery (RHA) and left hepatic artery (LHA), is observed in 29–85% of cases according to various authors [1, 2]. In the remaining percentage, one or another variant of arterial supply to the liver is encountered.

In his classical anatomical works based on 200 autopsies, N. Michels described ten major types of hepatic arterial anatomy [3]. According to this classification, all arteries participating in hepatic blood supply and not originating from the standard hepatic arterial system are referred to as aberrant, and further divided into supplementary arteries (supplying a portion of the lobe when a normal artery is present) and substitute arteries (supplying a lobe when no artery from the standard hepatic system exists). Michels’ classification remains widely used in surgical practice [3]. However, more than 50 additional, rarer variants of hepatic arterial supply have been described [1]. The right and left hepatic lobes may receive arterial blood partially or completely from the common hepatic artery, gastroduodenal artery, cystic artery, right diaphragmatic artery, splenic artery, right renal artery, or other visceral arteries, as well as from the ventral trunk or directly from the aorta, in numerous possible combinations [1].

With the rise of hepatopancreatobiliary and laparoscopic surgery, transplantology, and interventional radiology, interest in the vascular architecture of the liver has again intensified. Angiography remains the most accurate diagnostic method for determining hepatic arterial variants [1].

According to the study by Suman Tiwari et al., a left hepatic artery branching from the left gastric artery occurs in 6.1–21%, and the incidence in their material was 8% [4].

An aberrant common hepatic artery originating from the left gastric artery without connection to the gastroduodenal artery is extremely rare [5]. During gastrectomy, accidental ligation or injury of such an artery can lead to hepatic ischemia [5]. Reconstruction of CT images and detailed preoperative vascular assessment may therefore contribute to safer and faster gastrectomy [5].

Case presentation

A 58-year-old man of Azerbaijani ethnicity with biopsy-confirmed gastric cancer was referred to our department for surgical treatment. The patient initially presented with dyspeptic symptoms and unintentional weight loss. His medical history was otherwise unremarkable, with no significant comorbidities or previous abdominal surgery. There was no relevant family or psychosocial history.

Following diagnostic endoscopy and histopathological confirmation of gastric adenocarcinoma, the patient received four cycles of neoadjuvant chemotherapy using the FOLFOX regimen (5-fluorouracil, leucovorin, and oxaliplatin). The patient did not receive radiotherapy. Treatment was well tolerated, and no major adverse events were reported.

On physical examination at admission, the patient was in satisfactory general condition. Abdominal examination revealed no palpable masses, hepatomegaly, or signs of ascites. Laboratory tests, including liver function parameters, were within normal limits.

Preoperative contrast-enhanced CT demonstrated an aberrant left hepatic artery arising from the left gastric artery and suggested a replaced arterial supply to the left hepatic lobe. Its large caliber and surgical significance became fully evident during intraoperative dissection. Other major vascular structures, including the left gastric artery and common hepatic artery, arose in a typical configuration from the celiac trunk.

Following standard preoperative preparation, the patient underwent diagnostic laparoscopy, which was followed by total gastrectomy with end-to-side esophagojejunostomy and feeding jejunostomy. Intraoperatively, the tumor was located in the body of the stomach and was adherent to the pancreas and transverse colon without evidence of direct invasion. During mobilization of the gastrohepatic ligament, a large-caliber aberrant left hepatic artery was identified. The vessel originated from the left gastric artery, coursed along the superior margin of the left hepatic lobe, and entered the hepatic hilum as an independent trunk. The arterial diameter was estimated intraoperatively at approximately 15 mm and was consistent with measurements observed on preoperative CT imaging. The aberrant artery was carefully preserved throughout lymphadenectomy, and the procedure was completed without intraoperative complications.

Histopathological examination revealed a poorly differentiated gastric adenocarcinoma with metastatic involvement of 8 out of 39 resected lymph nodes. Resection margins were negative (R0). The final pathological stage was pT3N1M0.

The postoperative course was uneventful. Liver function tests remained within normal limits, and no signs of hepatic ischemia or biliary complications were observed. The patient resumed oral intake gradually and tolerated postoperative recovery without complications. He was discharged on postoperative day 9 in stable condition (Figs. 1, 2).

Fig. 1.

Intraoperative view of an aberrant left hepatic artery arising from the left gastric artery. The arrow indicates the aberrant left hepatic artery originating from the left gastric artery

Fig. 2.

Coronal contrast-enhanced computed tomography image demonstrating the aberrant left hepatic artery. The arrow indicates the aberrant left hepatic artery (ALHA)

The clinical timeline included diagnosis of gastric cancer, neoadjuvant chemotherapy, preoperative imaging, gastrectomy with D2 lymphadenectomy, and postoperative follow-up.

Discussion

Hepatic arterial variations are common anatomical findings; however, their clinical relevance largely depends on the size, dominance, and perfusion territory of the variant vessel [1, 3]. A left hepatic artery originating from the left gastric artery is a well-recognized variation, reported in 6–21% of individuals [4]. In most cases, this artery represents a small accessory branch and does not play a dominant role in hepatic perfusion.

In contrast, the aberrant artery observed in the present case was of large caliber and provided dominant arterial supply to the left hepatic lobe, consistent with a replaced left hepatic artery rather than an accessory vessel. Such dominant variants are uncommon and carry significant surgical implications, particularly during gastrectomy with D2 lymphadenectomy, where the left gastric artery and surrounding structures are routinely dissected [5].

From an embryological perspective, hepatic arterial variations arise from the persistence or regression of primitive ventral splanchnic arteries during early fetal development [3, 6]. Failure of normal involution may result in alternative arterial pathways supplying the liver, including hepatic branches originating from the left gastric artery. Understanding this embryological background helps explain the wide spectrum of hepatic arterial anatomy encountered in clinical practice and underscores why some variants, such as replaced hepatic arteries, can be of substantial caliber [6].

The oncologic and physiological rationale for preserving a dominant aberrant left hepatic artery is critical. Accidental ligation of such a vessel may lead to hepatic ischemia, postoperative liver dysfunction, or impaired healing of gastrointestinal anastomoses due to reduced hepatic arterial inflow [5, 7]. In patients undergoing neoadjuvant chemotherapy, preservation of hepatic perfusion may be even more important to ensure adequate postoperative recovery and liver function.

Preoperative identification of hepatic arterial variants is therefore essential. Multidetector computed tomography with angiographic reconstruction is currently the most reliable non-invasive method for detecting these variations and for assessing their size, course, and surgical relevance [5, 7]. In the present case, although the aberrant artery was visible on preoperative imaging, its dominant nature became fully evident during intraoperative dissection, highlighting the complementary role of imaging and surgical vigilance.

This case emphasizes the importance of careful dissection of the gastrohepatic ligament and routine awareness of possible vascular anomalies during gastrectomy. Recognition and preservation of a dominant aberrant left hepatic artery allowed safe completion of the procedure without postoperative hepatic complications.

Although a left hepatic artery arising from the left gastric artery is a known anatomical variant, this case highlights the importance of intraoperative recognition of a dominant replaced vessel and its preservation during oncologic gastrectomy with D2 lymphadenectomy. The report emphasizes surgical decision-making, correlation with preoperative imaging, and strategies to maintain hepatic perfusion.

Several anatomical and clinical studies have described variations of the hepatic arterial system, including a left hepatic artery arising from the left gastric artery [2, 7, 8]. Selected reports relevant to this vascular variation are summarized in Table 1.

Table 1.

Selected reports describing a left hepatic artery arising from the left gastric artery

Author	Year	Study type	Key findings	Difference from present case
Hiatt et al	1994	Anatomical study (1000 cases)	Described the frequency of hepatic arterial variations; a replaced or accessory left hepatic artery from the left gastric artery occurred in about 10% of cases	Large anatomical series without description of a specific surgical case or intraoperative management
Covey et al	2002	Angiographic study (600 patients)	Demonstrated the prevalence of hepatic arterial variants using digital subtraction angiography; variant LHA observed in ~ 20% of patients	Imaging-based study; did not describe intraoperative findings or surgical implications during gastrectomy
Noussios et al	2017	Literature review	Summarized hepatic arterial variations and emphasized their importance for hepatobiliary and upper gastrointestinal surgery	Review article without a specific clinical case demonstrating intraoperative identification
Noda et al	2020	Case report	Reported a rare aberrant common hepatic artery arising from the left gastric artery encountered during gastrectomy	Describes a different vascular anomaly involving the common hepatic artery rather than a replaced left hepatic artery
Present case	2025	Case report	Large-caliber replaced left hepatic artery originating from the left gastric artery identified during gastrectomy and preserved intraoperatively	Demonstrates correlation between preoperative CT findings and intraoperative recognition of a dominant replaced artery during oncologic gastrectomy

CT computed tomography; MRI magnetic resonance imaging; LHA left hepatic artery; LGA left gastric artery

Compared with previously reported studies, the present case highlights the importance of careful preoperative vascular evaluation and intraoperative vigilance during gastrectomy to prevent accidental ligation of a dominant replaced hepatic artery.

Conclusion

This case highlights a rare and clinically significant vascular variation: a dominant, large-caliber left hepatic artery originating from the left gastric artery and entering the liver as an independent trunk [4, 5]. Recognition and preservation of this artery were critical for the safe completion of gastrectomy. Detailed knowledge of hepatic arterial anatomy and preoperative vascular assessment are essential to prevent intraoperative complications.

Learning points

• Dominant aberrant LHAs from the LGA are rare but carry major surgical importance [4, 5].

• Accidental ligation may lead to hepatic ischemia and postoperative complications [5].

• CT angiography with reconstruction is essential for identifying dangerous vascular variants [5].

• Surgeons must remain vigilant during gastrohepatic ligament dissection and lymphadenectomy [1, 4].

Author contributions

All authors contributed to the conception, clinical management, drafting, and revision of the manuscript. All authors read and approved the final manuscript.

Funding

No external funding was received for this work.

Availability of data and materials

All data generated or analyzed during this study are included in this manuscript.

Declarations

Ethics approval and consent to participate

According to institutional and national guidelines, ethical approval was not required for this case report. Written informed consent was obtained from the patient for participation.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.