In about 15% of individuals, the hepatic artery supply is variant with accessory or replaced right or left hepatic arteries. The variant left hepatic usually arises from the left gastric, lies in the cephalad portion of the gastrohepatic ligament/lesser omentum, and is clinically significant when that membrane is divided (e.g. lap Nissen). The variant right hepatics arise from the superior mesenteric, run deep to the head of the pancreas and are relevant to hepatocystic triangle dissection and Whipple procedures. All variations are relevant to liver resection.
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When an aberrant left hepatic is encountered during lap Nissen, it is impossible to tell if it is accessory or replaced. If replaced, division could compromise blood supply to the left lobe. Portal blood flow could compensate for the loss, but all factors should be considered, and if the vessel can be preserved, that is the safest course.
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