Preservation of the ALHA (accessory left hepatic artery) in robot-assisted D2 gastric resections.

Graziano Pernazza, MD1, Pasquale Paolantonio, MD1, Francesca Abbatini, MD2, Riccardo Ferrari, MD1, Paolo Mazzocchi, MD1, Stefano Mattacchione, MD2, Carlo E Vitelli, MD1. 1AO San Giovanni Addolorata, Rome, IT, 2“Sapienza” University of Rome, Rome, IT


Technical challenges in gastric MIS has led to a more detailed studying of local anatomy in the preoperative workup.

Systematic preoperative multiphase 3D-CT scan allows to describe arterial and venous anatomy and to identify their variants, thus enabling to avoid accidental hemorrhage or ischemic liver damage and to accomplish a secure lymphadenectomy.


Since January 2010, 26 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically proven gastric adenocarcinoma were performed by a single surgeon.

CT-angiography (CTA) of splacnic vessels was performed using 64-MDCT scanner using a multiphase contrast-enhanced dynamic study.

In 8 cases the presence of an accessory left hepatic accessory artery (ALHA) coming from the left gastric artery (LGA) was detected. In 4 of them the ALHA was the unique tributary branch of the left liver.


Preservation of the ALHA was succesfully achieved in all the cases, completing the lymphadenectomy along the main trunk of the LGA, performing the division of the artery just above the origin of the ALHA.

Vascular lesions or bleeding during vascular skeletonization never occurred. Median number of harvested lymph nodes was 37,6 (23–44). Resection was radical (R0) in all the cases. Mean operative time was 305 min. No conversion occurred. Postoperative laboratory data indicating hepatic function were not altered.


Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step remains one of the most challenging tasks in conventional laparoscopic surgery, due to potential bleeding. Either in open and in minimally invasive surgery, systematic proximal division of the left gastric artery during D2 lymphadenectomy for gastric cancer is the usual procedure. In presence of an “accessory” or “replaced” left hepatic artery, this might induce transient postoperative liver dysfunction, but lethal complications, such as liver necrosis or death caused by division of the artery, have also been reported.

Lymphadenectomy can be more easily performed by using robot-assisted surgery, especially when an extended vascular preparation is requested.

In our experience of a consecutive series of 26 full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, ALHA emerging from the LGA was not uncommon (30,8%) even if the presence of a unique aberrant left hepatic artery emerging from the celiac trunk or the left gastric artery was a quite rare condition (15,4%).


Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique allowing an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity offering an extra-value in fine dissections around the vascular structures.

High resolution MDCT study may give useful information to plan the surgical procedure, preoperatively revealing eventual anatomical variations.

In our series, robotic assistance allowed to perform everytime a radical resection, achieveing an adequate number of lymphnodes, and preserving the accessory or unique “replaced” arterial vascularization to the left liver.

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