Laparoscopic total gastrectomy for advanced gastric cancer with anomalous splenic vein and celiac artery: A case report

Laparoscopic total gastrectomy for advanced gastric cancer with anomalous splenic vein and celiac artery: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Laparoscopic total gastrectomy for advanced gastric cancer with anomalous splenic vein and celiac artery: A case report Takahiro Tashiro, Hiroyuki Kato, Daisuke Koike, Tsunekazu Hanai, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6317617/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jan, 2026 Read the published version in BMC Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background Surgery for gastric cancer involves gastrectomy with lymph node dissection along the surrounding arteries. While arterial variations around the celiac axis are well recognized, venous anomalies such as an aberrant splenic vein are rare, and their surgical implications remain unclear. We aimed to report a case of laparoscopic total gastrectomy in a patient with an aberrant course of the splenic vein. Case presentation: An 80-year-old man diagnosed with Type 3 advanced gastric cancer of the lesser curvature of the gastric body was referred for surgery. Due to chronic renal dysfunction, computed tomography with contrast was was not possible, making it difficult to evaluate the course of the blood vessels. However, it was suggested that the common hepatic artery originated from the superior mesenteric artery. During surgery, the abnormal course of the common hepatic artery was confirmed, and additionally, the left hepatic artery was found to branch from the left gastric artery. Furthermore, the splenic vein coursed ventrally to the celiac artery. Although careful surgical procedures were required, total gastrectomy with D2 dissection was performed laparoscopically without any complications. Conclusions The awareness of anomalous vascular anatomy, including the splenic vein and hepatic artery, is essential for safe lymph node dissection during laparoscopic gastrectomy. Gastric cancer Laparoscopic total gastrectomy Splenic vein Vascular anomaly Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Gastric cancer is a common malignancy globally, and minimally invasive approaches are widespread and performed for early-stage and advanced cancers [ 1 ]. Surgery for gastric cancer carries morbidity and mortality risks, implying that technical and oncological safety is crucial [ 2 ]. Vascular injury is among the most critical intraoperative complications, potentially leading to pronounced bleeding or conversion to open surgery. The standard procedure for gastric cancer involves lymph node dissection around the upper abdominal arteries, such as the celiac axis, hepatic arteries, and splenic artery [ 1 ]. Many studies have described their frequency and branching patterns [ 3 – 5 ]. Multidetector computed tomography (CT) and three-dimensional reconstruction have improved the preoperative assessment of vascular anatomy. However, abnormalities in the portal venous system, including variations in the course of the splenic vein, remain partially elucidated [ 6 – 8 ]. Reports of anomalous splenic vein courses during gastrectomy are limited [ 9 – 11 ], and perioperative risk in such variations remains uncertain. Herein, we aimed to report a case of gastric cancer with an aberrant course of the splenic vein, which was associated with an anomalous hepatic artery and posed a potential risk of vascular injury during laparoscopic total gastrectomy. Case presentation The patient was a man in his 80s. He had lost his appetite for 2 months, and upper endoscopy revealed a Type 3 tumor extending from the lesser curvature to the upper part of the gastric body. Subsequently, he was referred for surgery. Biopsies confirmed an undifferentiated-to-moderately differentiated tubular adenocarcinoma (Fig. 1 ). He had hypertension, angina pectoris, and chronic renal dysfunction and was using several antihypertensive medications. His family history was negative. His body mass index was 16.5. In addition, he walked with a cane; however, his performance status was 1. Contrast-enhanced computed tomography (CT) was not possible due to renal dysfunction, but plain CT showed no distant metastasis, and the lymph nodes in the lesser curvature were swollen to ≥ 10 mm. The vascular course could not be fully evaluated because a contrast medium was not used; however, it was suggested that the common hepatic artery branched off the superior mesenteric artery (Fig. 2 ). A magnetic resonance imaging of the liver revealed a diffusion-restricted area at S2/3, so a contrast-enhanced echo was performed, and metastasis was ruled out. The clinical stage was diagnosed as cT4aN2M0 Stage III, and the preoperative risk assessment was ASA-PS 2. Before admission, the patient had lost 5 kg in 2 months. At admission, the albumin levels were low (2.2 g/dL); nevertheless, they were improved by nutritional support therapy, increasing to 2.8 g/dL. Laparoscopic total gastrectomy with D2 dissection and reconstruction were performed using the Roux-en-Y method. For dissection #6, the right gastroepiploic artery, which was thought to be branching off the right hepatic artery, was identified and resected. The duodenum was resected. When the lesser omentum was removed, the left accessory hepatic artery, which was not evident preoperatively, was identified and preserved. To dissect the upper border of the pancreas, the right gastric artery, which branches from the right hepatic artery, was excised, and the portal vein was identified on the dorsal side during dissection #12a along the right hepatic artery. During dissection #8a, the splenic vein was identified cranially to the pancreas. In its proximal part, the splenic vein ran along the cranial side of the pancreas and passed ventrally to the celiac trunk and proximal splenic artery. Dissections #8a, #9, and #7 were performed while avoiding the splenic vein. The two branches from the left gastric artery to the stomach were identified and treated. Dissection #11 was performed along the splenic artery (Fig. 3 ). The spleen was preserved, and total gastrectomy was performed. The postoperative course was uneventful, with no complications. The pathological examination revealed poorly differentiated adenocarcinoma with lymph node metastasis. The patient was diagnosed with pT4aN2M0 Stage IIIA (Fig. 4 ). Discussion and conclusions We performed laparoscopic total gastrectomy in a patient who presented with rare abnormalities in the courses of the arteries and the splenic vein running ventral to the celiac artery. Although we were unable to establish a preoperative diagnosis, lymph node dissection was performed along the dissectable layer by taping the splenic vein. In addition, retrospective reconstruction of the CT allowed us to identify vascular mutations. Regarding the splenic vein, there are large individual differences in the course of blood vessels around the splenic hilum; however, deviations in the positional relationship between the splenic artery and splenic vein, excluding the splenic hilum, have rarely been reported. Gerber et al. reported the following types: 1) the splenic vein runs dorsally to the splenic artery (54%); 2) the splenic artery and splenic vein partially cross (44%), and 3) the splenic vein runs ventrally to the splenic artery (2%) [ 6 ]. Skandalakis made a similar report [ 7 ]. There have also been reports on the classification of the cranial and caudal sides of the splenic artery. While the splenic vein mostly runs along the caudal side of the splenic artery, that running along the cranial side of the splenic artery is rare and can be classified into two types based on whether it runs cranial or caudal to the common hepatic artery [ 8 ]. Only a few case reports exist for gastric cancer surgery involving abnormalities in the splenic vein's position relative to the splenic artery, with only one paper in English and two in Japanese. Otani et al. found that the splenic vein ran cranially to the splenic artery in only two of 130 gastric cancer surgeries [ 10 ]. In our patient, the splenic vein ran along the cranial side of the pancreas in the proximal part, passed along the ventral side of the celiac artery, along the cranial and ventral sides of the splenic artery, crossed over in the distal part, and was on the dorsal side of the splenic artery. It was not possible to distinguish its position relative to the common hepatic artery because of an abnormality in the course of the common hepatic artery. The splenic vein ran along the ventral and cranial sides of the proximal portion, which is considered very rare. Only a few reports exist on the classification of the splenic artery into ventral and dorsal or cranial and pedicle sides. Considering the report by Otani et al., this is considered a rare abnormal course, and we believe that the types and frequency of abnormal courses of the splenic vein warrant clarification. Adachi classified the branching pattern of the celiac artery into 28 types and VI groups based on the findings of 252 cadaveric autopsies [ 4 ]. In this case, the right hepatic artery branched from the superior mesenteric artery, and the left hepatic artery further branched from the left gastric artery; therefore, it was considered the Adachi Type VI/Group 27. According to Michele’s classification, our case was Type IV [ 3 ]. In a study involving CT and DSA, this was rare, occurring in only one of 5,002 cases [ 12 ]. This is the first reported case of a patient with concurrent abnormalities in the splenic vein and artery courses. In patients with an abnormal vascular course, care must be taken to avoid vascular damage and perform optimal lymph node dissection. Lymph node dissection for gastric cancer is usually performed from the upper edge of the pancreas along the dissectable layer of the common hepatic and splenic arteries [ 13 ]. In this case, not only was the common hepatic artery absent, but the splenic vein also ran along the cranial side of the pancreas. Therefore, there was a risk of injury the splenic vein if lymph node dissection was performed along the artery as usual. Regarding the extent of lymph node dissection in gastric cancer, the common hepatic artery often used as a landmark, and Nodes #12a and #8a are often dissected. However, in cases of vascular abnormalities classified as Adachi Type VI, there is no common hepatic artery, and it is preferable to use the portal vein as a landmark for dissection [ 14 ]. In this case, the splenic vein was encircled and preserved for Dissections #8 and #11, and the splenic artery was dorsally dissected as a landmark. Three-dimensional (3D)-CT is crucial to understanding the abnormalities in the course of blood vessels before laparoscopic surgery for gastric cancer [ 5 ]. There are cases, such as this one, where the vascular course cannot be adequately evaluated preoperatively. In this case, we retrospectively constructed 3D images after surgery and examined the vascular course (Fig. 2 b). Radiologists at our hospital created 3D images of the vascular structure using plain CT without special instructions. It is difficult to accurately determine the abnormal vascular course from 2D images when it comes to abnormalities in the positional relationship rather than abnormalities in the branches; therefore, so we believe it is essential to create 3D images. In some cases, it is possible to create 3D images of the arteries and portal vein without contrast CT. Before surgery, it is necessary to thoroughly evaluate not only the course of the arteries but also the course of the splenic vein using 3D images. In conclusion, laparoscopic total gastrectomy was safely performed in a patient with anomalies in the splenic vein and hepatic artery. Although an anomalous course of the splenic vein is rare, it should be carefully considered preoperatively and intraoperatively to ensure safe lymph node dissection and avoid vascular injury. Abbreviations 3D: Three-dimentional; CT: Computed tomography; DSA: Digital subtraction angiography Declarations Acknowledgments We want to thank Editage (www.editage.com) for English language editing. Authors’ contributions TT and DK participated in the surgery of this case. TT and DK drafted this manuscript. MI, TH, YK, YA, HK, MS, TO, TK, YK, DT, KH, and AH reviewed and edited the manuscript. All authors approved the final version of the manuscript. Funding No author received any funding. Availability of data and materials All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate Ethics approval was waived because this is a case report. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. Competing interests The authors declare that they have no conflict of interest. References Japanese Gastric Cancer Association, Japanese Gastric Cancer Treatment Guidelines 2025 (7th edition). Katai H et al. Short-term surgical outcomes from a phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer: Japan Clinical Oncology Group Study JCOG0912. Gastric Cancer, 2017 Jul;20(4):699-708. Michels NA. Blood supply and anatomy of the upper abdominal organs: with a descriptive Atlas. New York: Lippincott. 1955 March. Adachi B et al. Das Arteriensystem der Japaner. Vol 2. Maruzen; 1928. Kishino T et al. Early gastric cancer with an Adachi type VI (group 26) vascular anomaly diagnosed preoperatively and treated by laparoscopic surgery: a case report. BMC Surg. 2021 Feb 23;21(1):99. Gerber AB et al: The surgical anatomy of the splenic vein. Am J Surg. 1951 Sep;82:339-343. Skandalakis PN et al. The surgical anatomy of the spleen. Surg Clin North Am. 1993 Aug;73(4):747-768. Akita K. et al: Vascular anatomy for diagnostic imaging and IVR: Liver, biliary tract, pancreas, spleen, portal venous system, general overview of the portal venous system. Japanisch-Deutsche Medizinische Berichte: 2007;52:82-105. Kishino T et al. A case of early gastric cancer in a patient with splenic vein angioplany. Jpn J Clin Oncol. 2019 Mar 1;49(3):291-292. Otani M et al. Pancreatic superior margin dissection considering splenic vein variation during laparoscopic gastrectomy. Syuzyutu. 2022 Jan;76(1):79-84 Tani R et al. Laparoscopic gastrectomy for early gastric cancer with anomalous splenic vein. Tokushima Red Cross Hosp Med J. 2016 Mar;21(1): 93-96(2016.03) Song SY et al. Celiac axis and common hepatic artery variations in 5002 patients- systematic analysis with spiral CT and DSA. Radiology. 2010 April;255(1):278-288. Shinohara H et al: Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema. Gastric Cancer. 2021 Mar;24(2):273-282. Kuramoto S et al: A study about gastric cancer with Adachi type VI vascular anomaly which was treated by laparoscopic gastrectomy. J Jpn Soc for Endosc Surg. 2015; 20:4:397-402. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Jan, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 10 Nov, 2025 Reviews received at journal 07 Nov, 2025 Reviewers agreed at journal 07 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviewers agreed at journal 02 Nov, 2025 Reviewers agreed at journal 31 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers invited by journal 30 Oct, 2025 Submission checks completed at journal 24 Oct, 2025 First submitted to journal 23 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6317617","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":537664413,"identity":"ea1e3855-aaf6-4a38-93b2-1a73d07bcf3f","order_by":0,"name":"Takahiro Tashiro","email":"","orcid":"","institution":"Fujita Health University School of Medicine, Bantane Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takahiro","middleName":"","lastName":"Tashiro","suffix":""},{"id":537664414,"identity":"bd1bb180-89f6-4937-9c58-430f55432f42","order_by":1,"name":"Hiroyuki Kato","email":"","orcid":"","institution":"Fujita Health University 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Upper endoscopy revealing a Type 3 tumor in the lesser curvature of the gastric body. b. Upper gastrointestinal contrast examination revealing a shadow defect from the gastric angle to the upper part of the gastric body.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6317617/v1/4edac9a166a38b8279bd1820.png"},{"id":94860780,"identity":"99c748ed-6f8c-4659-879b-70f63483aa7d","added_by":"auto","created_at":"2025-10-31 13:02:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":577551,"visible":true,"origin":"","legend":"\u003cp\u003ea. Computed tomogram revealing lymph node enlargement in the lesser curvature. b. Three-dimensional (3D) vascular reconstruction based on computed tomography (CT). The splenic vein runs cranially to the pancreas and ventrally to the celiac artery. The left hepatic artery has been replaced with the left gastric artery, the right hepatic artery has been replaced with the SMA–GDA, and the common hepatic artery is invisible at the upper edge of the pancreas.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6317617/v1/85e1bf414c47acce9c85422f.png"},{"id":94860783,"identity":"e12139ec-9a0e-4117-97c7-3e23333261b8","added_by":"auto","created_at":"2025-10-31 13:02:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2151091,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings.\u003c/p\u003e\n\u003cp\u003ea. Dissection of the upper border of the pancreas. The splenic vein runs on the cranial side of the pancreas, ventral to the celiac artery (taping of the splenic vein and the left gastric artery). b. Lymph node dissection around the left gastric artery. The common hepatic artery is not on the upper border of the pancreas, and the left hepatic artery branches from the left gastric artery. c. Dissection around the splenic artery. The splenic vein runs on the cranial side of the pancreas, ventral to the splenic artery in the proximal part, but on the dorsal side of the pancreas and posterior to the splenic artery in the distal part.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6317617/v1/940c1be8de2a5d9fc9dcc6eb.png"},{"id":94860788,"identity":"894484ac-4f92-45a4-81cc-992b8a2063d3","added_by":"auto","created_at":"2025-10-31 13:02:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1008771,"visible":true,"origin":"","legend":"\u003cp\u003ea. Gross findings of the resected stomach. b. Pathological finding of the resected stomach. The proliferation of atypical cells with little glandular lumen formation was observed.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6317617/v1/00ceaadf851b8f9e4aa76945.png"},{"id":101151750,"identity":"32e784e8-b456-4122-9460-844a7689b3c9","added_by":"auto","created_at":"2026-01-26 16:04:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5042640,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6317617/v1/23152f09-59ee-4f43-8f08-d67240869249.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic total gastrectomy for advanced gastric cancer with anomalous splenic vein and celiac artery: A case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGastric cancer is a common malignancy globally, and minimally invasive approaches are widespread and performed for early-stage and advanced cancers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Surgery for gastric cancer carries morbidity and mortality risks, implying that technical and oncological safety is crucial [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Vascular injury is among the most critical intraoperative complications, potentially leading to pronounced bleeding or conversion to open surgery. The standard procedure for gastric cancer involves lymph node dissection around the upper abdominal arteries, such as the celiac axis, hepatic arteries, and splenic artery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Many studies have described their frequency and branching patterns [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Multidetector computed tomography (CT) and three-dimensional reconstruction have improved the preoperative assessment of vascular anatomy. However, abnormalities in the portal venous system, including variations in the course of the splenic vein, remain partially elucidated [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Reports of anomalous splenic vein courses during gastrectomy are limited [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and perioperative risk in such variations remains uncertain. Herein, we aimed to report a case of gastric cancer with an aberrant course of the splenic vein, which was associated with an anomalous hepatic artery and posed a potential risk of vascular injury during laparoscopic total gastrectomy.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was a man in his 80s. He had lost his appetite for 2 months, and upper endoscopy revealed a Type 3 tumor extending from the lesser curvature to the upper part of the gastric body. Subsequently, he was referred for surgery. Biopsies confirmed an undifferentiated-to-moderately differentiated tubular adenocarcinoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). He had hypertension, angina pectoris, and chronic renal dysfunction and was using several antihypertensive medications. His family history was negative. His body mass index was 16.5. In addition, he walked with a cane; however, his performance status was 1. Contrast-enhanced computed tomography (CT) was not possible due to renal dysfunction, but plain CT showed no distant metastasis, and the lymph nodes in the lesser curvature were swollen to ≥ 10 mm. The vascular course could not be fully evaluated because a contrast medium was not used; however, it was suggested that the common hepatic artery branched off the superior mesenteric artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A magnetic resonance imaging of the liver revealed a diffusion-restricted area at S2/3, so a contrast-enhanced echo was performed, and metastasis was ruled out. The clinical stage was diagnosed as cT4aN2M0 Stage III, and the preoperative risk assessment was ASA-PS 2. Before admission, the patient had lost 5 kg in 2 months. At admission, the albumin levels were low (2.2 g/dL); nevertheless, they were improved by nutritional support therapy, increasing to 2.8 g/dL. Laparoscopic total gastrectomy with D2 dissection and reconstruction were performed using the Roux-en-Y method. For dissection #6, the right gastroepiploic artery, which was thought to be branching off the right hepatic artery, was identified and resected. The duodenum was resected. When the lesser omentum was removed, the left accessory hepatic artery, which was not evident preoperatively, was identified and preserved. To dissect the upper border of the pancreas, the right gastric artery, which branches from the right hepatic artery, was excised, and the portal vein was identified on the dorsal side during dissection #12a along the right hepatic artery. During dissection #8a, the splenic vein was identified cranially to the pancreas. In its proximal part, the splenic vein ran along the cranial side of the pancreas and passed ventrally to the celiac trunk and proximal splenic artery. Dissections #8a, #9, and #7 were performed while avoiding the splenic vein. The two branches from the left gastric artery to the stomach were identified and treated. Dissection #11 was performed along the splenic artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The spleen was preserved, and total gastrectomy was performed. The postoperative course was uneventful, with no complications. The pathological examination revealed poorly differentiated adenocarcinoma with lymph node metastasis. The patient was diagnosed with pT4aN2M0 Stage IIIA (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cp\u003eWe performed laparoscopic total gastrectomy in a patient who presented with rare abnormalities in the courses of the arteries and the splenic vein running ventral to the celiac artery. Although we were unable to establish a preoperative diagnosis, lymph node dissection was performed along the dissectable layer by taping the splenic vein. In addition, retrospective reconstruction of the CT allowed us to identify vascular mutations.\u003c/p\u003e\u003cp\u003eRegarding the splenic vein, there are large individual differences in the course of blood vessels around the splenic hilum; however, deviations in the positional relationship between the splenic artery and splenic vein, excluding the splenic hilum, have rarely been reported. Gerber et al. reported the following types: 1) the splenic vein runs dorsally to the splenic artery (54%); 2) the splenic artery and splenic vein partially cross (44%), and 3) the splenic vein runs ventrally to the splenic artery (2%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Skandalakis made a similar report [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. There have also been reports on the classification of the cranial and caudal sides of the splenic artery. While the splenic vein mostly runs along the caudal side of the splenic artery, that running along the cranial side of the splenic artery is rare and can be classified into two types based on whether it runs cranial or caudal to the common hepatic artery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Only a few case reports exist for gastric cancer surgery involving abnormalities in the splenic vein's position relative to the splenic artery, with only one paper in English and two in Japanese. Otani et al. found that the splenic vein ran cranially to the splenic artery in only two of 130 gastric cancer surgeries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our patient, the splenic vein ran along the cranial side of the pancreas in the proximal part, passed along the ventral side of the celiac artery, along the cranial and ventral sides of the splenic artery, crossed over in the distal part, and was on the dorsal side of the splenic artery. It was not possible to distinguish its position relative to the common hepatic artery because of an abnormality in the course of the common hepatic artery. The splenic vein ran along the ventral and cranial sides of the proximal portion, which is considered very rare. Only a few reports exist on the classification of the splenic artery into ventral and dorsal or cranial and pedicle sides. Considering the report by Otani et al., this is considered a rare abnormal course, and we believe that the types and frequency of abnormal courses of the splenic vein warrant clarification.\u003c/p\u003e\u003cp\u003eAdachi classified the branching pattern of the celiac artery into 28 types and VI groups based on the findings of 252 cadaveric autopsies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this case, the right hepatic artery branched from the superior mesenteric artery, and the left hepatic artery further branched from the left gastric artery; therefore, it was considered the Adachi Type VI/Group 27. According to Michele’s classification, our case was Type IV [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In a study involving CT and DSA, this was rare, occurring in only one of 5,002 cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This is the first reported case of a patient with concurrent abnormalities in the splenic vein and artery courses.\u003c/p\u003e\u003cp\u003eIn patients with an abnormal vascular course, care must be taken to avoid vascular damage and perform optimal lymph node dissection. Lymph node dissection for gastric cancer is usually performed from the upper edge of the pancreas along the dissectable layer of the common hepatic and splenic arteries [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this case, not only was the common hepatic artery absent, but the splenic vein also ran along the cranial side of the pancreas. Therefore, there was a risk of injury the splenic vein if lymph node dissection was performed along the artery as usual. Regarding the extent of lymph node dissection in gastric cancer, the common hepatic artery often used as a landmark, and Nodes #12a and #8a are often dissected. However, in cases of vascular abnormalities classified as Adachi Type VI, there is no common hepatic artery, and it is preferable to use the portal vein as a landmark for dissection [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this case, the splenic vein was encircled and preserved for Dissections #8 and #11, and the splenic artery was dorsally dissected as a landmark.\u003c/p\u003e\u003cp\u003eThree-dimensional (3D)-CT is crucial to understanding the abnormalities in the course of blood vessels before laparoscopic surgery for gastric cancer [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. There are cases, such as this one, where the vascular course cannot be adequately evaluated preoperatively. In this case, we retrospectively constructed 3D images after surgery and examined the vascular course (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). Radiologists at our hospital created 3D images of the vascular structure using plain CT without special instructions. It is difficult to accurately determine the abnormal vascular course from 2D images when it comes to abnormalities in the positional relationship rather than abnormalities in the branches; therefore, so we believe it is essential to create 3D images. In some cases, it is possible to create 3D images of the arteries and portal vein without contrast CT. Before surgery, it is necessary to thoroughly evaluate not only the course of the arteries but also the course of the splenic vein using 3D images.\u003c/p\u003e\u003cp\u003eIn conclusion, laparoscopic total gastrectomy was safely performed in a patient with anomalies in the splenic vein and hepatic artery. Although an anomalous course of the splenic vein is rare, it should be carefully considered preoperatively and intraoperatively to ensure safe lymph node dissection and avoid vascular injury.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e3D: Three-dimentional; CT: Computed tomography; DSA: Digital subtraction angiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTT and DK participated in the surgery of this case. TT and DK drafted this manuscript. MI, TH, YK, YA, HK, MS, TO, TK, YK, DT, KH, and AH reviewed and edited the manuscript. All authors approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo author received any funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was waived because this is a case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJapanese Gastric Cancer Association, Japanese Gastric Cancer Treatment Guidelines 2025 (7th edition).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKatai H et al. Short-term surgical outcomes from a phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer: Japan Clinical Oncology Group Study JCOG0912. Gastric Cancer, 2017 Jul;20(4):699-708.\u003c/li\u003e\n \u003cli\u003eMichels NA. Blood supply and anatomy of the upper abdominal organs: with a descriptive Atlas. New York: Lippincott. 1955 March.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdachi B et al. Das Arteriensystem der Japaner. Vol 2. Maruzen; 1928.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKishino T et al.\u003cem\u003e\u0026nbsp;\u003c/em\u003eEarly gastric cancer with an Adachi type VI (group 26) vascular anomaly diagnosed preoperatively and treated by laparoscopic surgery: a case report. BMC Surg. 2021 Feb 23;21(1):99.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGerber AB et al: The surgical anatomy of the splenic vein. Am J Surg. 1951 Sep;82:339-343.\u003c/li\u003e\n \u003cli\u003eSkandalakis PN et al. The surgical anatomy of the spleen. Surg Clin North Am. 1993 Aug;73(4):747-768.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAkita K. et al: Vascular anatomy for diagnostic imaging and IVR: Liver, biliary tract, pancreas, spleen, portal venous system, general overview of the portal venous system. Japanisch-Deutsche Medizinische Berichte: 2007;52:82-105.\u003c/li\u003e\n \u003cli\u003eKishino T et al. A case of early gastric cancer in a patient with splenic vein angioplany. Jpn J Clin Oncol. 2019 Mar 1;49(3):291-292.\u003c/li\u003e\n \u003cli\u003eOtani M et al. Pancreatic superior margin dissection considering splenic vein variation during laparoscopic gastrectomy. Syuzyutu. 2022 Jan;76(1):79-84\u003c/li\u003e\n \u003cli\u003eTani R et al. Laparoscopic gastrectomy for early gastric cancer with anomalous splenic vein.\u0026nbsp;Tokushima Red Cross Hosp Med J. 2016 Mar;21(1): 93-96(2016.03)\u003c/li\u003e\n \u003cli\u003eSong SY et al. Celiac axis and common hepatic artery variations in 5002 patients- systematic analysis with spiral CT and DSA. Radiology. 2010 April;255(1):278-288.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShinohara H et al:\u0026nbsp;Gastric equivalent of the \u0026apos;Holy Plane\u0026apos; to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson\u0026apos;s historic schema.\u0026nbsp;Gastric Cancer. 2021 Mar;24(2):273-282.\u003c/li\u003e\n \u003cli\u003eKuramoto S et al:\u0026nbsp;A study about gastric cancer with Adachi type VI vascular\u003cbr\u003e\u0026nbsp;anomaly which was treated by laparoscopic gastrectomy. J Jpn Soc for Endosc Surg. 2015; 20:4:397-402.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gastric cancer, Laparoscopic total gastrectomy, Splenic vein, Vascular anomaly","lastPublishedDoi":"10.21203/rs.3.rs-6317617/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6317617/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSurgery for gastric cancer involves gastrectomy with lymph node dissection along the surrounding arteries. While arterial variations around the celiac axis are well recognized, venous anomalies such as an aberrant splenic vein are rare, and their surgical implications remain unclear. We aimed to report a case of laparoscopic total gastrectomy in a patient with an aberrant course of the splenic vein.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eAn 80-year-old man diagnosed with Type 3 advanced gastric cancer of the lesser curvature of the gastric body was referred for surgery. Due to chronic renal dysfunction, computed tomography with contrast was was not possible, making it difficult to evaluate the course of the blood vessels. However, it was suggested that the common hepatic artery originated from the superior mesenteric artery. During surgery, the abnormal course of the common hepatic artery was confirmed, and additionally, the left hepatic artery was found to branch from the left gastric artery. Furthermore, the splenic vein coursed ventrally to the celiac artery. Although careful surgical procedures were required, total gastrectomy with D2 dissection was performed laparoscopically without any complications.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe awareness of anomalous vascular anatomy, including the splenic vein and hepatic artery, is essential for safe lymph node dissection during laparoscopic gastrectomy.\u003c/p\u003e","manuscriptTitle":"Laparoscopic total gastrectomy for advanced gastric cancer with anomalous splenic vein and celiac artery: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 13:02:26","doi":"10.21203/rs.3.rs-6317617/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-10T11:24:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-08T00:41:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249166311400107022106543829586849998643","date":"2025-11-08T00:08:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T09:18:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47678891958126057594881090619249139535","date":"2025-11-02T08:57:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119096074228274505013506972340966466568","date":"2025-10-31T06:55:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227126728736807253729260808424168793272","date":"2025-10-30T18:22:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T08:36:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-24T06:32:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-10-23T07:35:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73c202ae-8cb3-4c6f-9d4c-c7b6d7e6f74c","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:01:24+00:00","versionOfRecord":{"articleIdentity":"rs-6317617","link":"https://doi.org/10.1186/s12893-026-03515-w","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-01-23 15:58:14","publishedOnDateReadable":"January 23rd, 2026"},"versionCreatedAt":"2025-10-31 13:02:26","video":"","vorDoi":"10.1186/s12893-026-03515-w","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03515-w","workflowStages":[]},"version":"v1","identity":"rs-6317617","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6317617","identity":"rs-6317617","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}