the aberrant left hepatic artery ( alha ) is an arterial branch off of the left gastric artery and courses through the gastrohepatic ligament that provides blood supply to the left lobe of the liver . the importance and significance of an alha is greatest for liver transplantation and operations performed near the gastrohepatic ligament , including esophagogastrectomy , gastrectomy , gastric bypass , and antireflux procedures . although recent laparoscopic reports have only identified transient liver enzyme elevations with transection of the alha , reports exist of significant hepatic necrosis and even mortality after alha transection during esophagogastrectomy and gastrectomy . in the presence of an alha , hiatal dissection during antireflux procedures is more challenging . during laparoscopic fundoplication , preservation of the alha is optimal and can be accomplished with identification and meticulous dissection as reported in the adult literature . however , injuries to this artery have been reported in adults during laparoscopic reflux and gastric banding procedures with resultant transection of the artery . although recent reports in adults have documented safe division of this artery due to excessive bleeding , we believe a potential risk exists of hepatic ischemia . based on the adult literature , we sought to determine the incidence of alha in children undergoing laparoscopic nissen fundoplications and analyze intraoperative findings , surgical technique , and postoperative results . we documented intraoperative findings of each procedure and reviewed postoperative radiographic studies and clinic visits . all procedures were completed laparoscopically utilizing 5 ports ranging from 3 mm to 5 mm . a 4-mm 30-degree scope gastrohepatic ligament dissection was performed using electrocautery , preserving the alha ( figure 1 ) . gastrohepatic ligament dissection completed above and below an aberrant left hepatic artery ( arrow ) . after the crural repair , the fundus is tunneled behind the esophagus and caudal to the alha . first , we ensure that enough dissection has been performed to create a loose 360-degree wrap . then , the fundus is transposed from a caudal to cephalad position with regard to the alha . once we are satisfied with the wrap cephalad to the alha , 3 sutures are placed to complete a short ( 2-cm ) nissen fundoplication ( figure 2 ) . this study was reviewed and approved by the colorado multiple institutional review board ( comirb # 04 - 0769 ) . all dissections were performed laparoscopically with the completed nissen fundoplication positioned cephalad to the alha . one patient had an intact wrap with some slippage of the stomach through the wrap , but no gastroesophageal reflux . the remaining patients have had normal radiographic studies or no clinical evidence of reflux on follow - up clinic visits . moreover , no patient has had any clinical or radiographic evidence of distal esophageal stenosis due to a tight fundoplication . in this series of 195 patients undergoing laparoscopic nissen fundoplication , the incidence of alha was 15% . the problem upon encountering an alha is determining whether it is an accessory or replaced left hepatic artery . significant blood flow to the left lobe of the liver can arise from an alha and ligation of it can result in hepatic dysfunction , ranging from transaminase elevation to hepatic necrosis . in fact , during proximal gastric resection , if an alha is identified and poor collateral blood flow to the left lobe of the liver is suspected , then a left lobectomy has been advocated . during laparoscopic procedures , it is difficult to ascertain whether collateral blood flow to the left lobe of the liver would be sufficient if the alha is transected . therefore , during laparoscopic procedures , preservation of the alha is optimal because this artery may not be an accessory but rather an aberrant left hepatic artery . in adults , one series reported no transection of the alha , while another series reported that 36% of the alha had to be transected due to difficulty with the hiatal dissection , injury to the artery , or ongoing bleeding . in children , preservation of an alha may prevent safe dissection of the esophageal hiatus and make placement of the fundoplication difficult . unfortunately , no routine preoperative imaging studies are available that will delineate abnormal hepatic arterial anatomy . routine imaging studies usually consist of an upper gastrointestinal study to delineate esophageal , gastric , and duodenal anatomy , and confirm reflux . certainly , a celiac angiogram might demonstrate aberrant anatomy , but this is seldom used in children and has associated risks . to date , the ability to preserve an alha during a fundoplication and the effect on the outcomes of the procedure has never been evaluated in children . during this series , we were able to preserve all alha encountered and perform the fundoplication safely with no intraoperative complications . if the artery is injured or sacrificed , then blood flow to the liver will be compromised . dissection of the gastrohepatic ligament cephalad and caudal to the alha must be done meticulously to establish adequate visualization of the alha and allow for placement of the fundoplication . we have not encountered any difficulty with placing the 2-cm wrap cephalad to an alha once adequate dissection has been performed . both the surgeon and the pediatrician routinely see the patients in follow - up , with radiographic studies performed based on clinical symptoms of recurrent reflux . only 2 wrap failures ( 6% ) in patients with an alha have occurred . one patient had an intact wrap with some slippage of the stomach through the wrap , but no gastroesophageal reflux . our failure rate in patients with an alha is comparable to other published failure rates for laparoscopic nissen fundoplications in children . an aberrant left hepatic artery may be encountered in approximately 15% of children undergoing a laparoscopic nissen fundoplication . with attentive identification , meticulous dissection , and careful construction of the fundoplication , an alha may be routinely preserved . functional results in our patients with an alha have not been significantly different from results in our patients without an alha . for this reason , we believe that an alha should routinely be preserved when performing a laparoscopic nissen fundoplication in children .
objective : laparoscopic nissen fundoplication is performed in neonates and children for significant gastroesophageal reflux . an aberrant left hepatic artery encountered during laparoscopic 
 nissen fundoplication makes dissection around the esophageal hiatus more difficult if the artery is not transected . 
 although some suggest division of the aberrant left hepatic artery , this is associated with risk of significant hepatic injury from ischemia . 
 we routinely preserve the aberrant left hepatic artery and sought to determine ( 1 ) the incidence of aberrant left hepatic artery and ( 2 ) the results following preservation of the aberrant left hepatic artery.methods:between january 2000 and october 2002 , 195 laparoscopic nissen fundoplications were performed . 
 we documented intraoperative findings of each procedure , and reviewed postoperative radiographic studies and clinic visits.results:in 30 patients ( 15% ) , an aberrant left hepatic artery was identified . 
 all dissections were performed laparoscopically with the nissen fundoplication positioned cephalad to the aberrant left hepatic artery . 
 postoperatively , 2 patients ( 6% ) have had evidence of wrap failure . 
 the remainder of the patients has had normal radiographic studies or no clinical evidence of reflux during clinic visits.conclusion:during laparoscopic nissen fundoplication in neonates and children , an aberrant left hepatic artery may be encountered in approximately 15% of patients . 
 when an aberrant left hepatic artery is identified , it should be preserved to avoid the potential risk of hepatic ischemic injury .