Managing a Replaced Right Hepatic Artery During Robot-Assisted Pancreatoduodenectomy in Practical Steps.

Background: A replaced right hepatic artery (rRHA) arising from the superior mesenteric artery (SMA) is the most common hepatic arterial variant, occurring in ~12% of the population. Its close anatomical relationship with the pancreatic head poses significant challenges in hepatobiliary and pancreatic surgery, making it particularly vulnerable to injury during dissection. This can lead to ischemic complications or necessitate complex vascular reconstruction. In robot-assisted pancreatoduodenectomy (RPD) for resectable tumors, rather than focusing on resectability, the goal is to preserve the rRHA while ensuring an oncologically sound dissection. Thus, detection and precise understanding of the rRHA course and variations is essential.

Methods: We illustrate the management of rRHA in two patients with distinct anatomical features undergoing RPD. The first, a woman with distal cholangiocarcinoma and a low BMI (23 kg/m²), had close rRHA-pancreatic head connections. The second, a man with ampullary carcinoma and a higher BMI (26 kg/m²), presented with significant fat infiltration and a small-caliber rRHA.

Perioperative management: Preoperative high-resolution CT angiography mapped the vascular anatomy and guided surgical planning. Intraoperative strategies included meticulous dissection, early rRHA identification and vessel loop placement, SMA dissection, to end with rRHA origin dissection and control beneath the portal vein. These steps ensured preservation of the rRHA while maintaining oncologic integrity.

Conclusion: Preserving the rRHA during RPD requires a combination of detailed preoperative vascular mapping and intraoperative precision. Further studies are essential to refine and validate standardized strategies, with RPD rapidly becoming the standard of care in expert pancreatic centers.