Original Article

Yonago Acta medica 2015;58:157–164

Usefulness of Preoperative Assessment of Perigastric Vascular Anatomy by
Dynamic Computed Tomography for Laparoscopic Gastrectomy
Tomohiro Osaki, Hiroaki Saito, Yuki Murakami, Kozo Miyatani, Hirohiko Kuroda, Tomoyuki Matsunaga,
Youji Fukumoto and Masahide Ikeguchi

Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504,
Japan

ABSTRACT

the preoperative planning of LAG. Preoperative D-CT
might be an informative tool with which to help overcome the disadvantages of LAG.

Background

Laparoscopic surgery requires a moredetailed understanding of local anatomy than does conventional open surgery. The aim of this study was to examine the usefulness of dynamic computed tomography(D-CT) for identification of the location of the left gastric vein (LGV) and existence of the aberrant left hepatic
artery (ALHA) compared with conventional enhanced
computed tomography (E-CT).
Methods Sixty-eight patients underwent laparoscopicassisted gastrectomy (LAG). E-CT and D-CT were
performed in 32 and 36 patients, respectively, and threedimensional computed tomographic angiography (3DCTA) was performed in addition to D-CT. The locationof the LGV and existence of the ALHA were confirmed
during LAG, and these results were compared withthose determined preoperatively by CT imaging.
Results The location of the LGV as detected by preoperative E-CT and D-CT was consistent with that
identified during LAG in 28 (87.5%) and 31 (88.9%)
patients, respectively, with no statistical differences.
The existence of the ALHA as detected by preoperative E-CT and D-CT was consistent with that identified
during gastrectomy in 24 (75%) and 36 (100%) patients,
respectively, with a statistical difference (P = 0.005).
Furthermore, the type of ALHA could be identified in
10 of 12 patients (83.3%) by D-CT.
Conclusion D-CT can produce excellent images ofthe vascular supply, and thus undoubtedly contributes to

Key words

anatomy; computed tomography; gastrectomy; gastric cancer; laparoscopic surgery
Gastric cancer is one of the most common cancers inAsia, and its mortality rate ranks second among all cancer deaths worldwide.1 Complete tumor resection is the
only curative treatment for this disease. In Japan, gastrectomy with D2 lymph node dissection is widely accepted as a standard treatment for locally advanced gastric cancer. The vascular anatomy of the upper abdomen
is more complex than that of the lower abdomen becauseof vascular variations around the stomach; therefore, it isextremely important to identify these vascular variations
preoperatively. Identification of these vascular variations
also allows for precise lymph node dissection, which is
the most important part of gastrectomy for the treatmentof gastric cancer because surgeons consider the vessels
to be the landmarks in lymph node dissection.
Since 1994, laparoscopic-assisted gastrectomy(LAG) has been an increasingly popular treatment
method for early gastric cancer because it is considered
to be minimally invasive and to improve the quality oflife for patients after surgery.2–7 Moreover, because ofrecent advancements in laparoscopic surgical techniques
and related instruments, the indications for LAG havewidened.8 On the other hand, laparoscopic surgery has
various limitations derived from the lack of direct tactile
feedback and a two-dimensional display of the operative
field. Therefore, it is more important to preoperatively
comprehend the anatomic characteristics in patients undergoing LAG than in those undergoing open surgery.
The recent development of multidetector computed
tomography (MDCT) has made it possible to perform
three-dimensional computed tomographic angiography(3D-CTA), which appears to be an effective and reliable technique for evaluating the perigastric vascular
anatomy.9–15 However, this technique requires at least
two scanning phases. Additionally, a significant invest-

Corresponding author: Tomohiro Osaki, MD, PhD
t-osaki@med.tottori-u.ac.jp
Received 2015 September 11
Accepted 2015 October 15
Abbreviations: ALHA, aberrant left hepatic artery; ALT, alanine
aminotransferase; AST, aspartate aminotransferase; CA, celiac
artery; CHA, common hepatic artery; CT, computed tomography;
D-CT, dynamic computed tomography; E-CT, enhanced computed
tomography; GDA, gastroduodenal artery; HAP, hepatic arteryproper; LAG, laparoscopic-assisted gastrectomy; LGA, left gastricartery; LGV, left gastric vein; LHA, left hepatic artery; MDCT ,multidetector computed tomography; POD, postoperative day; PV,
portal vein; RHA, right hepatic artery; SA, splenic artery; SMA,
superior mesenteric artery; 3D-CTA, three-dimensional computed
tomographic angiography157

T. Osaki et al.

ment of time and effort is needed in the reconstructionof 3D-CTA than routine computed tomography (CT). To
date, no studies have compared conventional enhanced
CT (E-CT) with dynamic computed tomography (D-CT)
in terms of their usefulness in evaluating the perigastricvascular anatomy.
In the present study, we first determined whether
either E-CT or D-CT can detect the location of the
LGV and existence of the ALHA. This information isextremely important because of preventing the majorcomplications. The aim of this study was to compare theusefulness of D-CT including 3D-CTA for identificationof the perigastric vascular anatomy with that of E-CT.
To this end, the location of the left gastric vein (LGV)and existence of the aberrant left hepatic artery (ALHA)
were assessed by either E-CT or D-CT during a routine
check for metastasis.

start of the contrast medium injection, and the liver parenchymal-phase scanning was started at 120 s to scanfrom the diagram to the pelvis. The scanning parameters
were as follows: tube potential, 120 kVp; tube current,
automatic exposure control; gantry rotation speed, 0.5 s;helical pitch factor, 0.844 in E-CT and 0.641 in D-CT.
Scanning was performed with a 1-mm slice thickness
in both E-CT and D-CT. Postprocessing was performed
on a workstation (ZIOSTATION; Zio Software, Tokyo,
Japan). 3D-CTA images of the arteries and veins wereprepared separately by selecting a CT number tailored toa given target, and the images were colored. These images were then fused.
The imaging data were sent to the electronic chart,
and the CT slices were saved at every 5 mm because
the CT capacity for saving 1-mm slices in the electronic
chart was inadequate. These 5-mm slice CT images
were examined preoperatively by two surgeons (authorand second author) to detect the location of the LGVand existence of the ALHA. Two surgeons specialized
in gastric surgery and acquired endoscopic surgical skill
qualified surgeon. Two surgeons discussed CT images
each other before surgery at the same time. For the purposes of this study, the vessel connecting the portal or
splenic vein to the stomach was defined as the LGV. The
LGV was described as one of the following four types
based on its location: i) dorsal to the common hepatic artery; ii) ventral to the common hepatic artery; iii) ventral
to the splenic artery or iv) dorsal to the splenic artery (Fig.
1). The ALHA originates from the left gastric artery(LGA) and supplies a part of or the whole left hepatic
lobe. The ALHA can be classified as either “replaced,”which is a substitute for a normal left hepatic artery, or
as “accessory,” which is additive. However, subdivision

MATERIALS AND METHODS

Sixty-eight patients (49 males and 19 females) treated at
Tottori University Hospital and pathologically diagnosed
with gastric cancer were enrolled in this study. Noneof the patients received radiotherapy, chemotherapy, orother medical interventions before surgery. All patients
underwent CT scan using MDCT preoperatively to detect metastasis from the chest to the abdomen. CT was
performed with contrast media in all patients. E-CT
was performed in 32 patients and D-CT in 36 patients.
E-CT had already been performed in the digestive internal medicine department, and D-CT was performed
when CT had not been performed at the first medical
examination. All patients underwent LAG from June2010 to June 2012. Distal gastrectomy was performed
in 43 patients, total gastrectomy in 15 patients, proxiFig.1	
mal gastrectomy in 8 patients, and pylorus-preserving
gastrectomy in 2 patients. CT was performed using an
Aquilion 64-row multidetector CT scanner (Toshiba
Medical Systems, Tokyo, Japan). Non-ionic watersoluble iodine-containing contrast agent (510 mgI/kg per
60 s in E-CT, 570 mgI/kg per 30 s in D-CT) was intravenously injected. After 120 s, patients who underwent
E-CT were scanned from the chest to the abdomen. For
patients who underwent D-CT, the contrast-enhanced
CT arterial-phase images were obtained using thebolus-tracking method (called the “real prep method”
by Toshiba Medical Systems),16 which sets a region ofinterest in the aorta at the level of the bifurcation of theceliac artery and is designed so that imaging will begin
when the CT number of the region of interest is 100 HU
higher than that of the precontrast imaging. The scanning range delay for the first arterial phase was 20 to 25 s.
Portal venous-phase scanning was started 65 s after the

Aorta	
 

	
 A B

C D	
 
CA	
 

CHA	
 
	
 

	
 

	
 

SA	
 

Fig. 1. LGV was described as one of the following four types
based on its location: (A) dorsal to the common hepatic artery, (B)ventral to the common hepatic artery, (C) ventral to the splenicartery, or (D) dorsal to the splenic artery. CA, celiac artery; CHA,
common hepatic artery; LGV, left gastric vein; SA, splenic artery.

158

Dynamic CT for laparoscopic gastrectomy

into a “replaced” or “accessory” left hepatic artery could
not be definitively shown. In the preoperative imaging
evaluation and during surgery, a thick artery was usuallyconsidered as “replaced” and a thin one was regarded
as “accessory”.17 Our definitions of a “replaced” and“accessory” left hepatic artery by CT imaging were as
follows. If the ALHA was present by itself or the hepatic
artery proper was thicker than the left hepatic artery,
the ALHA was a “replaced” left hepatic artery. On theother hand, if the ALHA connected the hepatic arteryproper to the left hepatic artery in the hepatic portal
region or the hepatic artery proper was thinner than theleft hepatic artery, the ALHA was an “accessory” left
hepatic artery. The location of the LGV and existence of
the ALHA were confirmed during the gastrectomy andcompared with those determined preoperatively by CT
imaging.

the LGV as detected by preoperative E-CT and D-CT
was consistent with that identified during gastrectomy in
28 (87.5%) and 31 (88.9%) patients, respectively, with nosignificant difference (Table 1).
Assessment of ALHA by E-CT and D-CT

The existence of the ALHA was confirmed in 10 (31.3%)
patients in the E-CT group and in 12 (33.3%) patientsin D-CT group during laparoscopic gastrectomy. The
ALHA was confirmed in only 3 of 10 patients with detection of the ALHA by E-CT (Table 2). The accuracyof evaluation of the ALHA by E-CT and D-CT was
75% (24/32) and 100% (36/36), respectively; D-CT was
significantly more accurate than E-CT (P = 0.005) (Table
2).
Table 2. ALHA identification by either E-CT or D-CT
Intraoperative findings
Present
AbsentAssessment of perioperative liver function

The patients underwent routine hematological surveys ofliver function as assessed by aspartate aminotransferase(AST) and alanine aminotransferase (ALT) levels preoperatively and on postoperative days (PODs) 1, 3 and 7.

E-CT evaluation
Present
Absent3
7

1
21

Statistical analysis

D-CT evaluation
Present
120Absent024*D-CT was significantly more accurate than E-CT (P = 0.005).
ALHA, aberrant left hepatic artery; D-CT, dynamic computed
tomography; E-CT, enhanced computed tomography.

RESULTS

Identification of the type of ALHA by D-CT

Either the chi-squared test or Mann–Whitney U-test wasused to determine statistical differences between the twogroups. The accepted level of significance was P < 0.05.
GraphPad PRISM software (GraphPad Software, San
Diego, CA) was used for all statistical analyses.
Comparison of the location of the LGV as identified by E-CT and D-CT

As described above, the ALHA can be classified as either “replaced” or “accessory.” Representative imagesof a “replaced” and “accessory” ALHA by 3D-CTA
are shown in Fig. 3. In the D-CT group, 12 patients had
an ALHA (“replaced” in 5, “accessory” in 7). The typeof ALHA could be identified in 10 of these 12 patients(83.3%) by D-CT.

The LGV was intraoperatively identified in all patientsenrolled in the current study. The location of the LGV
was type A in 28 patients (41.2%), type B in 7 (10.3%),
type C in 28 (41.2%), and type D in 5 (7.3%). The representative CT images and intraoperative views of the
LGV of each type are shown in Fig. 2. The location ofAssessment of perioperative liver function
Table 1. Location of the LGV
Type

E-CT

Operation D-CT

Operation

A
15
16
11
12
B
6
7
0
0
C
5
5
20
23
D
2
4
0
1
Unknown
4
0
5
0
Total
32
32
36
36
Accuracy 87.5% (28/32)*
88.9% (31/36)**There was not significantly different between the two groups.
D-CT, dynamic computed tomography; E-CT, enhanced computed tomography; LGV, left gastric vein.

159

During surgery, the ALHA was divided when considered as “accessory” and preserved when considered
as “replaced.” The perioperative serum AST and ALTlevels are presented in Fig. 4. The serum levels of AST
and ALT on POD 1 were not significantly different between the ALHA-divided group (mean ± SE, 185.9 ±50.1 and 175.4 ± 47.0 IU) and ALHA-preserved group(135.5 ± 62.8 and 132.8 ± 62.4 IU; P = 0.91 and P = 0.85,
respectively). Furthermore, the serum levels of these enzymes on PODs 3 and 7 were not significantly different
between the two groups.

T. Osaki et al.

ahepatic artery	y	bFig.2b
Ventral to the common hepatic artery	cdFig.2dDorsal to the splenic artery 	Fig. 2. Representative CT images and intraoperative views of each type of LGV.
a: Dorsal to the common hepatic artery. b: Ventral to the common hepatic artery. c: Ventral to the splenic artery. d: Dorsal to thesplenic artery. CA, celiac artery; CHA, common hepatic artery; LGA, left gastric artery; LGV, left gastric vein; PV, portal vein; SA,
splenic artery; SV, splenic vein.

160

Dynamic CT
for laparoscopic gastrectomy
Fig.3baccessory ALHA

Fig.3areplaced ALHAab

accessory ALHA	LHA	

replaced ALHA	

LGA	
CA	

RHA	

RHA	
HAP	
CHA	
GDA	

LGA	

CA	

GDA	

SMA	
PHA	

SA	

SA	

Fig. 3. Representative images of “replaced” and “accessory” ALHA by 3D-CTA.
a: Replaced ALHA: No LHA from the hepatic artery proper is present. This ALHA supplies the whole left hepatic lobe. b: Accessory
ALHA: Arises from the LGA and connects to the HAP in the hepatic portal region. ALHA, aberrant left hepatic artery; angiography;
CA, celiac artery; GDA, gastroduodenal artery; HAP, hepatic artery proper; LGA, left gastric artery; LHA, left hepatic artery; SA, splenic artery; SMA, superior mesenteric artery; RHA, right hepatic artery; 3D-CTA, three-dimensional computed tomographic angiography.

Operation time, blood loss volume, and total number of dissected lymph nodes

the LGV. In the present study, the type of LGV anatomy
could be preoperatively detected in 87.5% of patients by
E-CT and in 88.9% by D-CT. Kawasaki et al.14 previously showed that the accuracy of detecting the correct
location of the LGV by preoperative CT was 93.8%,
which is similar to our findings. Importantly, there wasno difference between E-CT and D-CT in terms of detecting the LGV, indicating that D-CT is not necessary
to detect the correct location of the LGV.
The ALHA originates from the LGA and supplies
a part of or the whole left hepatic lobe. The incidenceof an ALHA varies from 6.5% to 30.0% in the literature.17–20 The significance of this anomalous vessel has
also been described in visceral surgery of the upper intestinal tract and liver transplantation.20 During curative
gastrectomy for gastric cancer, extended lymph nodedissection requires division of the LGA and resection of
all elements of the lesser omentum. The LGA must be
exposed to complete the gastrectomy with lymph nodedissection. The LGA is usually ligated and divided at
its origin to allow for complete dissection of the lymph
nodes. However, an ALHA arising from the LGA as avariation of the LGA is sometimes observed. An ALHA
can be classified as either a “replaced” artery, which is a
substitute for a normal left hepatic artery, or an “accessory” artery, which is present in addition to the normal
artery. The division of a replaced left hepatic arterymight induce transient liver dysfunction during the early
postoperative period. Lethal complications, such as liver

The operation time was 377.5 ± 100.4 and 396.6 ± 128.5
min in the ALHA-preserved group and ALHA-divided
group, respectively, with no significant difference (P= 0.97) (Fig. 5a). The blood loss volume was 60.83 ±86.6 and 145.6 ± 260.5 mL in the ALHA-preserved
group and ALHA-divided group, respectively, with nosignificant difference (P = 0.24) (Fig. 5b). Furthermore,
there was no significant difference in the total numberof dissected lymph nodes between the ALHA-preserved
group and ALHA-divided group (29.7 ± 9.8 vs. 47.1 ±
20.9, respectively; P = 0.10) (Fig. 5c).
DISCUSSION
In the present study, we first determined whether either
E-CT or D-CT can detect the location of the LGV andexistence of the ALHA. This information is extremely
important because accidental injury of the LGV often
occurs due to the various patterns of its inflow and route
relative to the surrounding arteries. Because of the major
blood flow within the portal vein and splenic vein, into
which the LGV and mesenteric vein flow, injury to the
LGV leads to heavy blood loss and difficulty in hemostasis, even in open gastrectomy. Preoperative assessment of the LGV anatomy seems to be more importantin LAG than in open gastrectomy because knowledgeof the LGV anatomy prior to surgery enables surgeons
to confidently proceed with the manipulation around161

Fig.4a	
T. Osaki et al.

a

AST (POD1)

Fig.4bn=6135.5 ± 62.8 	

AST (POD1)

n = 16185.9 ± 50.1 	

n=6
132.8 ± 62.4 	

P = 0.85 	

P = 0.91 	

b

AST (POD3)

Fig.4c 	 n = 6

AST (POD3)

n = 1648.9 ± 7.2 	

36.0 ± 9.5 	

n=6
73.5 ± 34.7 	

AST (POD7)

n = 1695.9 ± 18.6 	

P = 0.34 	

P = 0.20 	

cn = 16175.4 ± 47.0 	

125

AST (POD7)

100
75
50
25
0

n=6
29.3 ± 6.6 	

n = 1628.4 ± 2.9 	

n=6
51.0 ± 14.4 	

n = 1646.0 ± 6.2 	

P = 0.71 	

P = 1.0 	

Fig. 4. Perioperative liver function.
a: The serum AST and ALT levels on POD 1 were not significantly different between the ALHA-divided group andALHA-preserved group. b, c: The serum AST and ALT levels on PODs 3 and 7 were also not significantly different
between the two groups. ALHA, aberrant left hepatic artery; ALT, alanine aminotransferase; AST, aspartate aminotransferase; POD, postoperative day.

162

ig.5a 	Fig.5bDynamic
CT for laparoscopic gastrectomy
Fig.5babn=6375.5 ± 100.4 	c 	

n = 16396.6 ± 128.5 	

n =n 6= 6
60.8± 86.660.8± 86.6

P = 0.97 	

cnn == 1616
145.6
145.6 ±± 260.5
260.5

0.24
PP
= =0.24

Total nodal dissection

Fig. 5. Operation time, estimated blood loss volume, and total
number of dissected lymph nodes. There were no statistically significant differences in the (a) operation time, (b) estimated blood
loss volume, or (c) total number of dissected lymph nodes between the ALHA-divided and ALHA-preserved groups. ALHA,
aberrant left hepatic artery

n=6
29.7 ± 9.8 	

n = 1647.1 ± 20.9 	

presence of an ALHA by D-CT including 3D-CT is extremely useful for planning of LAG. In the current study,
there were no differences between the ALHA-preserved
group and ALHA-divided group in terms of operation
time, blood loss volume, or total number of dissected
lymph nodes, indicating that the ALHA-preserving procedure did not affect the quality of LAG. On the other
hand, there was no difference in liver function as evaluated by the serum AST and ALT levels despite the factthat the accessory ALHA was divided, indicating thatthe accessory ALHA can be safely divided. Therefore,
D-CT may be indispensable to avoid lethal liver-related
complications.
In conclusion, our findings in the current study demonstrate that D-CT is extremely useful for assessment of
the perigastric vascular anatomy before LAG for gastriccancer. Preoperative D-CT might be an informative toolwith which to help overcome the disadvantages of LAG.

P = 0.10 	

necrosis or death caused by division of the artery, havealso been reported.21–24 Therefore, it would be betterto preserve a replaced ALHA to avoid lethal complications, especially in patients with early gastric cancer.17,
24
In this study, D-CT including 3D-CTA was more
useful for detection of the ALHA than was E-CT. More
importantly, D-CT especially 3D-CTA was extremely
useful to confirm the type of ALHA. In fact, the type of
ALHA could be identified in 10 of the 12 patients (83.3%)
by D-CT in the current study.
Although it is not so difficult to detect the existenceof an ALHA intraoperatively, even during LAG, it issometimes difficult to confirm the type of ALHA during
the operation. Therefore, preoperative assessment of the

The authors declare no conflict of interest.

163

T. Osaki et al.
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