presented herein is a case in which an aberrant right hepatic artery ( rha ) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry .
a 54-year - old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy . 

laparoscopic dissection revealed an aberrant right hepatic artery ( rha ) anterior to the infundibulum and fundus of the gallbladder .
further dissection revealed the cystic artery to branch laterally off this rha over the gallbladder fundus anteriorly .
the cystic artery then wrapped postero - laterally on the gallbladder 's surface to its neck .
after the gallbladder was removed , the aberrant rha was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location .
the origins and paths of both the cystic and right hepatic arteries have several documented anomalies . 
 we are unaware of any reports of an rha that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry .
this case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy . 

ligation of this uniquely located aberrant rha could have led to intraoperative hemorrhage or potential hepatic ischemia .
the extrahepatic vascular and biliary anatomy of calot 's triangle is well known to be inconsistent and highly variable .
careful dissection of the cystic duct and artery is required with a constant mind on the numerous anatomical possibilities to avoid both conversion requiring hemorrhage and postoperative biliary leak .
presented herein is a case in which an aberrant right hepatic artery ( rha ) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry .
a 54-year - old female presented to her primary care physician with complaints of intermittent epigastric pain accompanied by nausea and vomiting .
her symptoms did not last longer than 15 minutes per episode and had been occurring 2 to 4 times per week for 2 months .
the patient was given the diagnosis of biliary colic and scheduled for an elective laparoscopic cholecystectomy .
at operation , the procedure was initiated with establishment of pneumoperitoneum and the standard two 12-mm and 10-mm trocars in the midline with two 5-mm ports laterally .
these adhesions were seen as likely evidence of previous gallbladder inflammation despite no such ultrasound findings .
immediately visible upon retraction of the gallbladder was a thick tissue band covered in omental remnants extending from the area of the common bile duct towards the infundibulum . initially thought to be the cystic duct , the size and path of this structure was not compatible .
dissection of adhesions revealed the structure to be an aberrant right hepatic artery adherent to the anterior surface of the gallbladder , enveloped in its peri - toneal covering .
further dissection revealed the cystic artery to branch laterally off this rha over the gallbladder fundus anteriorly ( figure 1 ) .
the cystic artery was clipped and ligated and the rha was completely freed from the gallbladder .
the gall - bladder was then able to be retracted superolaterally allowing dissection of the cystic duct .
the duct was clipped proximally and left open for insertion of cholangio - catherization ( figure 2 ) .
after the gallbladder was removed , the aberrant rha was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location ( figure 3 ) .
the remainder of the procedure was completed as an uncomplicated laparoscopic cholecystectomy . the aberrant right hepatic artery ( above right angle dissector ) adherent to the anterior surface of the gallbladder .
the cystic artery branches off this rha and wraps laterally around the gallbladder towards the infundibulum . with the cystic artery ligated and the right hepatic artery dissected off the gallbladder , the gallbladder was then able to be retracted laterally , allowing for cystic duct identification and ligation for cholangiography .
after the gallbladder has been removed , the right hepatic artery is elevated with a probe to illustrate its high site of hepatic entry .
superiorly , the artery has adherent remains of omental tissue residual from the preoperative inflammation and adhesions .
the origins and paths of both the cystic and right hepatic arteries have several documented anomalies .
a single cystic artery with a dominant course originating at the flexure of the right hepatic artery within calot 's triangle passing posteromedially to the cystic duct toward the gallbladder neck is most common ( 70% to 80% ) . in approximately 5% of patients , the cystic artery courses outside of calot 's triangle to the gallbladder .
frequently seen cystic artery variants include double artery ( 15% to 20% ) , cystic artery originating from an aberrant right hepatic artery ( 5% to10% ) , left hepatic artery origin ( 1% to 3% ) , and gastroduodenal artery origin ( 3% to 7% ) .
studies of hepatic arterial anatomy during liver harvesting for transplantation provide an excellent database documenting anomalies .
a replaced rha is seen in 15% to 25% of patients , of which the vast majority reveal the rha branching off the superior mesenteric artery .
other aber - rant rha sources are the gastroduodenal artery , right gastric artery , and aorta .
while the rha is seen anterior to the junction of the cystic and common bile ducts in a quarter of patients , these pass posteromedially to the gallbladder and cystic duct before entering the liver . while an rha adherent to the cystic duct and gallbladder neck is described amongst the most rare of anomalies , we 
 are unaware of any reports of an rha that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry .
inadvertent right hepatic artery ligation in cholecystectomy has been associated with liver ischemia , sometimes warranting hepatic lobectomy .
an angiographic study would be needed to confirm the origin of this rha and whether it was an accessory rha or a true single aberrant rha  this , however , was not clinically indicated .
the size of the vessel ( figures 1 and 2 ) alone is sufficient evidence of its significance .
based on historically observed patterns , this rha was most likely of superior mesenteric origin .
this case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy .
ligation of this aberrant rha could have led to intraoperative hemorrhage or potential hepatic ischemia .
 introduction : presented herein is a case in which an aberrant right hepatic artery ( rha ) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry.case report : a 54-year - old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy . 
 
 laparoscopic dissection revealed an aberrant right hepatic artery ( rha ) anterior to the infundibulum and fundus of the gallbladder . 
 further dissection revealed the cystic artery to branch laterally off this rha over the gallbladder fundus anteriorly . 
 the cystic artery then wrapped postero - laterally on the gallbladder 's surface to its neck . 
 after the gallbladder was removed , the aberrant rha was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location . 
 intraoperative images are included . 
 the procedure was completed laparoscopically without complication.discussion:the origins and paths of both the cystic and right hepatic arteries have several documented anomalies . 
 
 we are unaware of any reports of an rha that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry.conclusion:this case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy . 
 
 ligation of this uniquely located aberrant rha could have led to intraoperative hemorrhage or potential hepatic ischemia . 