Variations in the cystic and iliolumbar arteries with Psoas

Variations in the cystic and iliolumbar arteries with Psoas

Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P. 56-60
Case Report:
Variations in the cystic and iliolumbar arteries with Psoas minor muscle
1Dr.
5Dr.
Sibani Mazumdar, 2Dr. Susumna Biswas , 3Dr. Tridib Kumar, 4Sett Dr. Manotosh Banerjee ,
Barnali Mukherjee , 6Dr. Paramita Mukhopadhyay , 7Dr. Sudeshna Majumdar , 8Dr. Reshma Ghosh
1Professor and
Head, Department of Anatomy, Calcutta National Medical College, Kolkata - 700014, West Bengal, India.
2Demonstrator,
Department of Anatomy, Nilratan Sircar Medical College, Kolkata – 700014, West Bengal, India.
3Associate Professor,
Malda Medical College and Hospital, Malda – 732101, West Bengal, India.
4Junior Resident,
Department of Anatomy, Nilratan Sircar Medical College, Kolkata – 700014, West Bengal, India.
5Junior Resident,
Department of Anatomy,KPC Medical College, Kolkata – 700032, West Bengal, India.
6Assistant Professor,
7Professor,
Department of Anatomy, Nilratan Sircar Medical College, Kolkata -700014, West Bengal, India.
Department of Anatomy, Nilratan Sircar Medical College, Kolkata -700014, West Bengal, India.
8Junior Resident,
Department of Anatomy,Nilratan Sircar Medical College, Kolkata – 700014, West Bengal, India.
Corresponding author: Prof. (Dr.) Sudeshna Majumdar
Date of submission: 23 May 2014; Date of Publication: 15 September 2014
ABSTRACT
The knowledge of multiple variations in peripheral blood vessels and muscles is important as these structures can be injured
during a surgical procedure or regional anaesthesia. Some unusual clinical symptoms may arise due to these variations. While
doing the routine dissection for MBBS Students, in the Department of Anatomy, NRS Medical College, Kolkata, India, few
variations were found in abdomen of two male cadavers in December, 2013. In one cadaver, the cystic artery arose from the
gastroduodenal artery. In the second cadaver, iliolumbar artery originated from the left common iliac artery and the psoas minor
muscle was present on both sides. This case report will enhance our knowledge in gross and clinical anatomy.
KEY WORDS: Hepatic artery, cystic artery, gastroduodenal artery, iliolumbar artery, psoas minor muscle
INTRODUCTION
cystic artery often varies. The most common variant
According to normal anatomy, the hepatic artery,
is an origin from the common hepatic artery,
after its origin from the celiac axis, passes antero-
sometimes from the left hepatic or gastroduodenal
laterally to the upper border of the first part of the
artery1.
duodenum. It may be subdivided into the common
The abdominal aorta bifurcates into right and left
hepatic artery (from the coeliac trunk to the origin of
common iliac arteries to the left side of the fourth
the gastroduodenal artery), and the hepatic artery
lumbar vertebral body. In addition to external iliac
‘proper’ (from the point of origin of gastroduodenal
and internal iliac arteries each common iliac artery
artery to its bifurcation into right and left hepatic
also gives small branches to the peritoneum, psoas
1
arteries at the porta hepatis) . The cystic artery
major, ureter, adjacent nerves and surrounding
usually arises from the right hepatic artery and passes
areolar tissue. Each internal iliac artery divides into
anterior to the cystic duct and reaches the superior
one anterior and one posterior trunk, behind the
aspect of the neck of gallbladder to divide into
superior margin of the greater sciatic foramen.
superficial and deep branches. The origin of the
Iliolumbar artery is usually the first branch of the
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Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P. 56-60
posterior trunk of the internal iliac artery. It ascends
muscle. On right side, the iliolumbar artery arose
laterally anterior
from the posterior division of the internal iliac artery
to the sacroiliac joint
and
lumbosacral trunk to reach the medial border of the
as usual.
psoas major muscle where it divides into lumbar and
Moreover, psoas minor muscle was present on both
iliac branches. The common iliac artery occasionally
sides in the posterior abdominal wall of the second
1
gives rise to Iliolumbar artery .
cadaver. Both the muscles ended into long tendons
Psoas minor is a muscle of the posterior abdominal
in the lower part.
wall. It is often absent, but when present, lies anterior
to the psoas major. It arises from the bodies of the
12th thoracic and 1st lumbar vertebrae and from the
disc between them. It ends in a long flat tendon
attached to the pectineal line and ileopectineal
eminence of the hip bone and laterally to the iliac
fascia1.
MATERIALS AND METHODS
While doing the routine dissection for MBBS
students in December, 2013, few variations were
found in the abdomen of two male cadavers, in the
Department of Anatomy, NRS Medical College of
Figure – 1; The cystic artery (D) arose from the
Kolkata, India. One subject was about sixty years old
gastroduodenal artery (C) instead of the right hepatic
and the other was about seventy years. Dissection
artery (E), passed upwards and it inclined towards the
was done properly in abdomen of the two cadavers.
gallbladder (G) on right side.
All the structures were observed minutely and
Index: A – Common hepatic artery, B – Hepatic
relevant photographs were taken.
artery proper, C – Gastroduodenal artery,
OBSERVATIONS
D - Cystic artery, E – Right hepatic artery, F – Left
In the first cadaver, the cystic artery arose from the
hepatic artery, G – Gallbladder,
gastroduodenal artery instead of the right hepatic
artery, passed upwards to the right side and it
H – Liver, I – Common bile duct, J– Ist part of the
duodenum.
inclined towards the cystic duct and gall- bladder.
The hepatic artery proper divided into right and left
hepatic branches below the porta hepatis, before
running into the liver parenchyma as usual.
Medworld asia
In the second cadaver, the left iliolumbar
artery originated from the left sided common iliac
Dedicated for quality research
artery (instead of the posterior division of the internal
iliac artery). Then it divided into iliac and lumbar
arteries reaching the medial border of the psoas major
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Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P. 56-60
Index: A- Left psoas major muscle, B - Left kidney,
C – Left ureter, D - Abdominal Aorta,
E - Left common iliac artery, F - Left lateral
femoral cutaneous nerve.
DISCUSSION
The cystic arteries vary markedly in regard to the
arterial stem from which they arise. A cystic artery
arise from a source other than the right hepatic artery
in about 10% of the bodies2,3.
Daseler et al (1947)
Figure – 2; In the second cadaver, the left iliolumbar
found in their study that in 85-90% cases cystic artery
artery (A) originated from left the sided common
arose from the right branch of the hepatic artery and
iliac artery (B) and it divided into two branches
in 2.5% cases from the gastroduodeanal artery3.
reaching the medial border of psoas major (C).
According to Hollinshead (1971), this artery may
arise from the aberrant right hepatic artery, the left
hepatic artery (in about 5% cases or more), branches
of the coeliac trunk, or even from the superior
mesenteric artery4. Bergman et al stated that the
cystic artery may arise from the downward-directed
vessel, the gastroduodenal artery, or its branch, the
superior pancreaticoduodenal artery. Origin from the
more distant source is far less common (0.3%) than
Figure – 3; Right sided psoas minor muscle (lying on
the belly of psoas major muscle) was held with forceps.
the nearer (2.6%) 5.
Pushpalatha et al (2010) found in their study
Index: A – Right psoas major muscle, B – Right
that the cystic artery arose from the right hepatic
kidney, C – Right lateral femoral cutaneous nerve, D –
artery in 54% cases, from the hepatic artery proper in
Right ureter, E – Abdominal Aorta, F – Right common
22% cases, from the common hepatic artery in 12%
iliac artery.
cases, from the gastroduodenal artery in 8% cases,
from the superior mesenteric artery in 2% cases and
from the accessory hepatic artery in 2% cases6. In
another study, among 150 cases, cystic artery arose
from the right branch of the hepatic artery proper in
147 (98%) cases and from the gastroduodenal artery
in 3 (2%) cases (including a case of double
gallbladder) 7. According to another recent study
most common source of origin of the cystic artery
Figure – 4; Left sided psoas minor tendon (lying on
was the right hepatic artery in 92% cases, followed
the belly of psoas major muscle) was held with
by aberrant right hepatic artery in 4% cases, the left
forceps.
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Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P. 56-60
hepatic artery in 1% case and the gastroduodenal
8
of the femur or lesser trochanter with psoas major11.
artery in 1% case .
Knowledge of cystic artery variability, as
revealed
from
may end on the iliac fascia, inguinal ligament, neck
facilitates
the second part lying deep to the first. A subdivision
intraoperative identification of vessels in both
or splitting of its tendon may occur with one part
classical
cholecystectomy or
going to the fifth lumbar and the first sacral
surgery of bile ducts. Uncontrolled bleeding from
vertebrae, and the second going to the iliopectineal
cystic artery and its branches may increase the risk of
line. This was also observed that this muscle had
lesions to vital vascular and other structures during
been replaced by a tendon or its insertion lost in the
hepatobiliary surgery and also during other upper
pelvic fascia12.The psoas minor muscle has been
abdominal surgeries like resection of pancreas 6, 9.
clinically ignored as a functional hip flexor. Patient
and
different
laparoscopic
studies,
According to Macalister this muscle may be doubled,
The Iliolumbar artery, though it is usually the
complaints of pain in the anterior inguinal area
first branch of the posterior division of the internal
during psoas minor strain which will interfere with
iliac artery, may be absent, reduced in size, or
their ability to run, jump or rotate on hip joint13.
partially replaced by one of the lumbar arteries. It
CONCLUSION
occasionally gives rise to a lateral superior sacral
This case report with variant anatomy of the cystic
artery10. It has been occasionally seen as a branch of
artery may be of help for the surgeons to minimize
the common iliac, one lumbar, middle sacral and the
the risk of haemorrhage and injury to vital structures
lateral sacral
including biliary apparatus during upper abdominal
arteries 1,10.
surgeries like cholecystectomy
6,8
. The variation in
Psoas minor muscle is not constant in
the iliolumbar artery and the presence of psoas minor
humans. In a report of 182 subjects it was present on
muscle are also important for surgery in the posterior
both sides in 70 subjects, on the right side in 12, on
abdominal wall. Psoas minor strain has importance in
the left side in 8, and absent on both sides in 92
Sports Medicine.
subjects. Various sources report that the muscle is
ACKNOWLEDGEMENT
11
present in about 56% of bodies . When present, the
We are grateful to all the members of the Department
muscle varies considerably in its site of origin. It may
of Anatomy, Nilratan Sircar Medical College,
be connected only with the first lumbar vertebra, or
Kolkata –14, West Bengal, India, for their cordial
with the second lumbar and intervertebral disc (above
help to complete this case report.
it) or it may arise from two heads. At its insertion it
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