Background : Pancreatoduodenectomy in presence of hepatic arterial anomalies is technically challenging. In cases of type 9 hepatic artery (common hepatic artery arising from superior mesenteric artery) extreme care needs to be taken to preserve hepatic arterial supply without compromising oncological principles.

Methods : Case 1 and 2 - Adult patients with diagnosis of periampullary carcinoma planned for laparoscopic pancreatoduodenectomy. On preoperative CT scan type 9 hepatic artery anomaly was detected. Both patients had common hepatic artery originating from superior mesenteric artery 1-2 centimeters after its origin from aorta. The common hepatic artery was seen coursing behind common bile duct; turning to the left by partial encirclement of common bile duct and then lying in its normal position in hepatoduodenal ligament. Gastroduodenal artery located near right border of common bile duct. In both cases laparoscopic resection was done successfully without injuring the common hepatic artery and achieving adequate oncological clearance. We routinely divide common bile duct at the end of resection, but in these two cases it was divided earlier for safe dissection. Case 3 - This case was also a periampullary carcinoma planned for open pancreatoduodenectomy due to pancreatitis history. In this case the common hepatic artery was originating from superior mesenteric artery at a level 6 centimeters from its origin. Also it was seen coursing in between pancreatic head and portal vein behind the pancreatic neck. It was isolated by an 'uncinate first' approach and dissected away from pancreatic parenchyma after dividing the neck Case 4 - Periampullary carcinoma planned for open pancreatoduodenectomy. The type 9 hepatic artery anomaly was not detected preoperatively and intraoperatively. It was accidentally ligated at the origin and a segment was lost along with the specimen. To restore hepatic artery blood flow, rotation graft was done using middle colic artery.

Results : Cases 1,2 and 3 did well in postoperative period. All three had transient elevation of transaminases. Case number 4 had acute liver failure with sepsis which lead to multi-organ failure and could not be salvaged.

Conclusions : Pancreatoduodenectomy is safe and feasible in presence of type 9 hepatic arterial anomaly by both open and laparoscopic approach. Good quality multi-planar triphasic CT is recommended as a preoperative imaging of choice. Level of origin and course of type 9 common hepatic artery varies from case to case. Preoperative planning is crucial to prevent poor perioperative outcomes.