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C. Fang and Z. Fang
physical models, the accurate spatial anatomy of the hepatobiliary and pancreatic vessels and lesions can be obtained.
The 3D physical models restore the real spatial position of
the intrahepatic vessels, provide more detailed information
for real-time surgery, and reduce potential complications of
surgery; furthermore, these models can be brought into the
operation room and placed in an appropriate place to provide
an intuitive navigation for the key steps of hepatobiliary and
pancreatic surgeries. In addition, the printed 3D models and
the patient’s hepatobiliary and pancreatic organs can be synchronously adjusted in the process of surgical anatomy and
organ separation; thus, the key anatomical sites can be
quickly identied and located. By establishing a high-precision preoperative model or intraoperative template, the technique can improve surgical precision and reduce surgical
trauma, thus conforming to the modern concept of precision
surgery. During surgical planning, the 3D physical model
can be used for patient assessment, surgical protocol formulation, and simulation operation; at the same time, the 3D
printing model can be applied to guide the operation in real
time, which ensures a more precise and safer operation.
Moreover, these 3D printing applications enable a better
doctor–patient communication and increase the trust between
the two parties because they enable patients and their relatives to intuitively understand the surgical plans and risks.
5.3.1 Application of3D Printing inLiver
Surgery
5.3.1.1 In Complex Liver Resection
At present, there are various denitions for complex liver
tumors:
• Centrally located hepatocellular carcinoma involving the
porta hepatis.
• Tumors with variations of hepatic artery, portal vein, and
hepatic vein within the liver.
• Intrahepatic vascular malformations caused by severe
tumor compression.
• Hepatic malignancy with tumor thrombus in the inferior
vena cava and/or right atrium.
• Large benign or malignant liver tumors requiring exten-
sive hepatectomy.
• Liver tumor encroaching on hepatic segments I and VIII
that need to undergo complex liver resection.
Because of the complex vascular structure and their variations, it is necessary to (a) understand the variations of hepatic
vessels in hepatic surgery, and (b) locate the position of liver
tumor and liver vessels precisely before operation. The 3D
printing application of a liver model can truly display the location, size, and shape of the tumor; moreover, the relationship
between the tumor and vessels can be observed from all direc-
tions. 3D models present the features of organs as in vivo,
which can provide intuitive real-time indirect navigation during surgery and help to quickly identify and locate the key
parts. 3D printing can make the anatomy of the complex hepatectomy clearer and the operation more precise and controllable. Clinically, the Couinaud liver segmentation method is the
result of invitro liver cast studies, and its concordance with
most cases is only 20% to 30% (Cho etal. 2005). Individualized
hepatic segmentation can be carried out based on an individual
patient’s blood ow topology by using 3D visualization technology for the study of hepatic segmentation. The hepatic segment of each functional area is determined by the independent
portal vein blood supply and hepatic venous reux. Accurate
division of conventional and abnormally distributed liver segments facilitates a more intuitive and accurate response to the
spatial location of tumor lesions. For patients with complex
liver tumors requiring hepatectomy, 3D printed liver segmentation based on hepatic vein and portal vessels are more conducive to planning for surgery (Fig.5.6). Igami etal. used a 3D
print of the liver for hepatectomy, which indicates that the
application of 3D printing is very helpful in guiding real- time
hepatectomy (Igami etal. 2014). The authors believe that 3D
image reconstructions based on patient MDCT data are usually displayed on a two-dimensional screen; different physicians have different perceptions of the spatial anatomical
relationship between vascular and hepatic tumors; however,
by observing 3D printed physical models, all physicians can
identify them. In order to complete the resection of liver segments VII and VII, which are located under the apical part of
the right diaphragm (special site), the right hepatic ligament
should be dissociated and the deep vascular structure of the
hepatic segment should be dissected. For such a complex liver
resection, 3D printing is invaluable. A 3D print of the liver is
benecial for anatomical hepatectomy. A 3D model can help
locate the key parts of the deep vascular structure of the liver,
and thus contribute to a successful operation. Yamazaki etal.
believed that the relationship between hepatic vessels and
tumor was the most important spatially adjacent relationship
in hepatic anatomical hepatectomy (Yamazaki and Takayama
2019). In their study, a simplied 3D printed model (printing
the lesion and its surrounding blood vessels) was used to guide
anatomic hepatectomy in real time for hepatocellular carcinoma at segment VII.By intraoperative navigation of the 3D
print model, the Glisson pedicle of segment VII was found and
thus, the anatomical liver resection of segment VII was successfully performed. For liver tumor at segments IV and VII
involving the middle hepatic vein, anatomical radical resection of segment IV and the ventral anterior hepatic region were
successfully carried out by using a simplied 3D printing
model. This study indicates that a mere 3D print of hepatic
vessels and tumor lesions is effective in guiding anatomical
hepatectomy, and such a 3D printed model is helpful for all
liver surgeries. Professor Fang Chihua’s team applied 3D
printing technology to preoperative planning and intraopera-
ab
5 Application of3D Printing Technology inHepato-Biliary-Pancreatic Surgery
ba
125
Fig. 5.6 3D visualization of liver segments based on topological drainage of hepatic veins and portal veins. (a) Front view; (b) diaphragmatic
surface view. Note: Red for the celiac artery system, dark blue for the
Fig. 5.7 (a, b) 3D printed model of complex liver cancer; front view. Note: Red for the celiac artery system is in red, dark blue for the hepatic
vein system, and light blue for the portal vein system
tive guidance of 22 patients undergoing complex liver resection (Xiang et al. 2015). Their results showed that the 3D
printed model can stereoscopically display the spatial relationship between liver tumor and intrahepatic vessels, help to
dene the liver pre-resection surface, and ensure accurate
operation. Fang etal. used 3D visualization and 3D printing
physical models for preoperative planning and evaluation of
liver volume, as well as for guiding the successful operation of
right lobe massive liver tumors with vascular variability. In
this case, if right hepatectomy was performed according to
conventional surgery, the residual liver volume would be 41%,
theoretically; however, due to vascular variations (portal vascular variation in hepatic segment IV arising from the right
hepatic vein system, light blue for the portal vein system, and magenta
for the ventral side of the liver.
anterior branch of the portal vein), conventional right hepatectomy would result in no portal blood supply in segment S4
(ischemia), which would result in insufcient postoperative
residual liver volume (residual liver volume was 21%). Using
3D visualization and 3D printing for preoperative surgical
planning and intraoperative 3D printing for surgical navigation, reduced right hepatectomy was performed and the portal
blood supply of segment IV was retained. The operation was
successful and the patient recovered smoothly. This case study
shows that liver 3D printing assisted surgery for massive liver
tumor with variations in portal veins is a safe and effective
method to improve the success rate and reduce the risk of surgery (Fig.5.7).
126
C. Fang and Z. Fang
5.3.1.2 In Liver Transplantation
Many severe hepatobiliary diseases can lead to liver failure
at the end of the period and liver transplantation may become
the only treatment option. These diseases include primary
sclerosing cholangitis, cholangiocarcinoma, diffuse
intrahepatic cholelithiasis, end-stage biliary disease, and
childhood congenital biliary disease. With further
improvements in transplant surgery and surgical techniques,
severe hepatobiliary disease will be treated by liver
transplantation more often. The complexity of the hepatic
vascular system poses a challenge to liver transplantation.
By using 3D visualization and printing technology, the
intrahepatic vascular and biliary structures can be observed
stereoscopically and the donor and recipient’s hepatic
vascular anatomy can be well known before operation. Zein
etal. carried out a research on the application of 3D printed
intrahepatic conduit physical models in living donor liver
transplantation (Zein et al. 2013). Three donor livers and
three recipient livers were printed into 3D translucent models
and these models were used for preoperative planning and
intraoperative indirect navigation. 3D physical models help
to understand the anatomical relationship between hepatic
vessels and bile ducts, and to shorten the operative time and
surgical complications. The liver model was compared with
the resected real liver; the average deviation of the 3D model
(length, width, and height) was less than 4 mm, and the
average deviation of vessel diameter was less than 1.3mm.
Ikegami etal. argued that in living donor liver transplantation,
it is very important to accurately assess the liver volume as
well as to delineate the resection plane (Ikegami and Maehara
2013). If the liver volume of the donor is overestimated, it
may lead to postoperative “small liver syndrome.” When
deviation from the pre-resection plane occurs during
hepatectomy, it may result in a smaller graft from the donor
liver that is expected to be transplanted; or damage to the
remaining liver tissue of the donor liver may increase postoperative complications. The transparent 3D printed model
of the liver can easily, during the operation, solve the above
problems due to the opacity of the liver, and the invisibility
of the blood vessels and bile ducts within the liver. Moreover,
3D printing of liver can also reduce the loss of liver tissue of
potential donors in pediatric liver transplantation; by printing
the abdominal cavity of the recipient, it is possible to assess
whether the graft is suitable for the abdominal cavity, thereby
reducing the “large liver syndrome” in pediatric liver transplantation. Therefore, the occurrence of vascular complications (such as portal vein thrombosis, hepatic artery
thrombosis, and hepatic vein stenosis) caused by this syndrome can be decreased, and prognosis can be improved.
With the advancement of medical 3D printing technology,
the 3D printed liver model can be used to accurately assess
the liver volume and visualize the accurate anatomical location of the liver, which is conducive to pediatric living donor
liver transplantation.
5.3.2 Application of3D Printing inBiliary
Diseases
5.3.2.1 In Cholangiocarcinoma Surgery
In general, radical hepatectomy is currently the main treatment method for biliary malignancies such as intrahepatic
cholangiocarcinoma and hilar cholangiocarcinoma. Accurate
intraoperative location of hepatic vascular structure (hepatic
vein and portal vein tree), bile duct structure, and tumor
lesions is very important, because the operation planning and
real-time surgical resection process are dependent on the
spatial relationship of these important anatomical
structures.
The diagnosis and treatment of hilar cholangiocarcinoma
is a difcult point in biliary surgery. The application of 3D
printing technology provides strong support for the
implementation of surgical scientic planning and accurate
intraoperative surgery. For patients with hilar
cholangiocarcinoma who need right hemi-hepatectomy/
extended right hemi-hepatectomy, partial hepatic artery or
portal vein resection, or vascular reconstruction, 3D printing
(Fig. 5.8) on the basis of 3D visualization research and
analysis is very helpful. The Bismuth-Corlette typing of hilar
cholangiocarcinoma can be analyzed by omnidirectional and
multi-angle observation of the 3D printed model, including
the anatomical course and variation of hepatic vessels and
bile duct trees, the location and size of tumor lesions and
their relationship with important vascular structures. It is
helpful to systematically reect the anatomical location of
the tumor in the biliary tract system and analyze the
inltration of the tumor into the surrounding structures
(especially the vascular results). This is conducive to
preoperative judgment of the resectability of the tumor and is
also helpful for the selection of individual surgical methods.
3D printing techniques can guide accurate anatomical
hepatectomy or periportal hepatectomy of hilar
cholangiocarcinoma, reduce operation time and the incidence
of postoperative complications.
5.3.2.2 In Complex Surgery forHepatolithiasis
With the advancement and popularization of imaging technology and the improvement of hepatobiliary surgery techniques, the overall diagnosis and treatment of hepatolithiasis
have been greatly improved, and the residual stone rate after
surgery has been signicantly reduced. However, the diagnosis and treatment of complex hepatolithiasis have always
been a difcult and contentious issue in biliary surgery, and
it remains a great challenge to deal with. There is still no unied concept for complex hepatolithiasis. Lau etal. (2017)
proposed that complex hepatolithiasis mainly includes the
following types:
• One or more bile duct surgeries have been performed due
to bile duct stones, but reoperation is required because of
5 Application of3D Printing Technology inHepato-Biliary-Pancreatic Surgery
127
ab
Fig. 5.8 Front view of 3D printed model of hilar cholangiocarcinoma. Note: Red for the celiac artery system, dark for the hepatic vein system,
light blue for the portal vein system, yellow for the dilated bile duct, and brown for the hilar bile duct tumor
residual stones, recurrence, or recurrent cholangitis
episodes.
• Reoperation is needed because of inappropriate biliary
tract surgery performed in the past, such as various biliary
anastomoses.
• Stones are distributed on both sides of the liver.
• Stones combined with high stenosis or Caroli disease.
• Stones associated with biliary cirrhosis and portal
hypertension.
• Stones associated with cholangiocarcinoma.
The lack of accurate diagnosis and reasonable treatment
may lead to repeated operations of patients. Repeated
operations may result in biliary cirrhosis, end-stage biliary
disease, or eventually cholangiocarcinoma, seriously
affecting the quality of life and survival of patients. For
patients with complex hepatolithiasis, the location of stones,
the course and variation of bile ducts, and the anatomic
relationship between blood vessels and bile duct can be
clearly displayed by 3D printing, which is helpful to analyze
which surgical treatment is most scientic. The 3D printed
intrahepatic duct model can help to observe the spatial
relationship between intrahepatic anatomy, lesions, and
intrahepatic vessels and/or bile ducts from multiple angles to
ensure the feasibility, accuracy, and controllability of the
operation. The liver 3D printing model, which faithfully
displays the spatial relationship between the stones and the
liver vessels, is brought into the operating room. Under the
real-time indirect navigation of 3D models, the operation can
be carried out smoothly.
Zheng etal. (2017) showed that among 42 cases of complex hepatolithiasis, 24 cases underwent 3D printing assisted
surgery, and 28 cases underwent conventional CT imaging
assisted surgery. The former was superior to the latter in
terms of operation time, intraoperative bleeding volume,
residual rate of immediate calculi, nal residual rate, and
complication rate. Their study indicated that 3D printing
technology leads to shortened operation time, reduced blood
loss, reduced incidence of complications, and accelerated
recovery of patients. In recent years, Professor Fang Chihua’s
team has applied 3D reconstructed models and 3D physical
printed models to the clinical diagnosis and treatment of
hepatolithiasis, constructed a 3D diagnosis and treatment
platform for hepatolithiasis, and achieved digital anatomy,
diagnostic programming, and visualization of minimally
invasive surgery for hepatolithiasis (Fang etal. 2015). Their
protocols have the following advantages:
• Accurate location of stones accurately and reduction of
repetitive operations for patients with complex biliary
structures. For the treatment of diffuse hepatolithiasis,
hard stone lithotripsy can improve the rate of hepatectomy
with a single operation.
• Determination of the surgical resection plane during hep-
atectomy; which is helpful for indirect navigation for the
separation of important vessels and the entire resection of
hepatolithiasis and diseased bile ducts, so as to: reduce/
avoid injury of important anatomical structures, reduce
the risks of surgery, reduce surgical complications, and
improve prognosis.
128
ab
C. Fang and Z. Fang
Fig. 5.9 (a, b) 3D printed models of complex hepatolithiasis; front view. Note: Red for the celiac artery system, dark blue for the hepatic vein
system, green for the dilated bile duct, light blue for the portal vein system, and white for hepatolithiasis
Professor Fang Chihua’s team used 3D printed models to
guide the operation of complicated hepatolithiasis, which
has achieved good short-term results (Fig.5.9).
Through 3D printing, the preoperative analysis of a 3D
physical model of the pancreas is helpful to further understand
the patient’s condition; moreover, 3D printed models can
help patients and their relatives understand the complexity of
the lesion and the risk of surgery. By using these models,
5.3.3 Application of3D Printing inPancreatic
Surgery
surgeons can perform preoperative planning and outcome
prediction for patients under a simulated environment
approximate to the real world. 3D printing technology can
Pancreatic cancer is a refractory malignant tumor of the
digestive system, with hidden onset, difcult early diagnosis,
rapid progress, and poor prognosis. The 5-year survival rate
is ≤6% (Jemal etal. 2010). Pancreatic surgery is challenging
in modern surgery, not only because of the structural
characteristics of the pancreas itself, but also the structural
relationship of the pancreas and its surrounding structures
including the duodenum, common bile duct, portal vein,
superior mesenteric artery, superior mesenteric vein, and
celiac trunk artery. Therefore, to evaluate the feasibility of
the operation, devise the surgical plan scientically, make
and implement accurate surgical treatment; it is very
important to analyze the normal anatomy and variation of the
patients before operating.
Through 3D printed pancreas, the relationship between
pancreatic tumors and structures such as peripancreatic
vessels can be truthfully demonstrated, so that the operators
can clearly and intuitively understand the anatomy of the key
sites and perform the surgical operations accurately. This
will result in shortened operation time, reduced blood loss,
and reduced incidence of intraoperative complications.
provide accurate data and rich information for the actual
clinical surgery, reduce intraoperative bleeding, shorten
operation time, reduce complications, and lower risks.
3D visualization for pancreatic head carcinoma plays an
important role in accurate preoperative diagnosis, resectability assessment, and individualized surgical planning. 3D
printing of the pancreas can help to realize a leap-forward
transformation from a 3D visualization image to the physical
model, so as to better guide accurate surgery of complex pancreatic head tumor. The advantages of pancreatic 3D physical
model printing: In the cases of complex pancreas and ampullary tumors with close relationship between tumor and portal
vein, as well as superior mesenteric vein and superior mesenteric artery, 3D visualization of pancreas was performed after
obtaining 3D visual data, and then intraoperative indirect
navigation was performed to ensure the smooth implementation of the operation. Dr. Xiang Nan etal. performed a 3D
physical printing model on complex pancreatic head and periampullary tumors (Xiang 2016). By observing the 3D model,
the following information can be accurately and comprehensively diagnosed:
ab
5 Application of3D Printing Technology inHepato-Biliary-Pancreatic Surgery
129
• The shape and location of the tumor.
• The location and degree of expansion of the bile duct and
pancreatic duct obstruction.
• The morphological change of the pancreas.
• The spatial relationship between the tumor and the surrounding large blood vessels.
room and compared with actual surgery in real time. By
continuously adjusting, the 3D printed model can be placed
into the best anatomical position and can provide intuitive
indirect navigation and guide key surgical procedures. It also
conrms that a 3D printed pancreas can help to accurately
locate lesions, quickly identify key anatomical sites, and
contribute to successful completion of complex pancreas
These factors are helpful to assess the resectability of the
tumor and determine the surgical resection plane. The 3D
printed model of the pancreas was brought into the operation
surgery (Figs.5.10 and 5.11). The application of 3D printing
technology in preoperative planning and indirect navigation
during operation, can improve the safety of surgery, reduce
ab
Fig. 5.10 3D printed physical model of pancreatic tumor. (a) Front view; (b) back view. Note: Brown for the pancreatic head tumor and light blue
is the portal venous system
Fig. 5.11 3D printed physical model of ampullary tumor. (a) Front
view; (b) back view. Note: Gray for the ampullary tumor, brown for the
enlarged lymph nodes, light blue for the portal venous system, green for
the dilated bile duct system, red for the celiac artery system, and white
for the stent
130
C. Fang and Z. Fang
intraoperative inadvertent injury, reduce postoperative
complications associated with pancreatic cancer surgery, and
thus contribute to better postoperative recovery. These
virtues are in harmony with the concept of enhanced recovery from hepatobiliary and pancreatic surgery.
The 3D print of the pancreas can better assist the preop-
erative evaluation and planning of pancreatic cancer surgery
and help to improve the safety of surgery. However, as a relatively new technology in clinical applications, 3D printing
technology for pancreas surgery requires a large number of
clinical data and further large randomized controlled trials to
verify its effects.
5.3.4 Prospects
Along with the research and development of biomaterials
and 3D printing technology, the efciency of 3D printing for
hepatobiliary and pancreatic diseases will be greatly
improved, and the cost will be reduced simultaneously. Also,
rapid and high-delity 3D printing will be available for other
parts of the human body. Through formulating innovative
solutions to old problems, a new canvas is provided for innovative thinkers to write new chapters of modern surgery.
Revolution in 3D printing technology has touched upon surgery; printing and transplanting the entire organ may become
ordinary one day in the future.
Lipson, the famous robot engineer pointed out optimisti-
cally that 3D printing will bring forth a revolution in the
medical eld. Since the mapping of the human genome, personalized medicine is coming. Personalized 3D printing is
playing an increasingly important role, from nutrition
deployment to prosthetic equipment and medical implant
production. More areas being impacted by this technological
revolution include biological printing equipment, surgical
operation training, and even printing of the precise drug dosage requirements customized to individual patients. This
technology can also inuence and penetrate into the clinical
diagnosis and treatment in many ways (Lipson 2013).
The application of 3D printing technology in hepatobili-
ary and pancreatic surgery is still in early development, and
more research is needed. We rmly believe that the use of
this technology will be expanded in the future and will
enhance the diagnosis and treatment of hepatobiliary and
pancreatic surgery disease, so that more patients will benet
and truly enjoy the higher quality of life brought by scientic
and technological developments.
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Virtual Surgical Instruments
andSurgical Simulation
SusuBao, JiahuiPan, XuChang, DongboWu,
andChihuaFang
6
6.1 Introduction
Rapid advances in modern biliary surgery are inseparable
from the evolution of science and technology and their applications in medicine. In recent years, computer technology
has been increasingly applied in the eld of modern medicine with the continuous advance of computer technology
and medical imaging technologies such as CT and
MRI.Unfortunately, these medical imaging devices can only
provide a two-dimensional (2D) grayscale image of the
human body. Physicians can only estimate by experience the
size and shape of the lesions as well as the number and location of the stones based on multiple 2D images, and then
“conceive” the 3D geometric relationship between the
lesions and the surrounding tissues. This poses great challenges to the diagnosis and management of biliary diseases.
Moreover, because of the complexity and variability of the
structure of the liver and biliary tract, the unclear intraoperative denition of the diseased area is a key issue, with the
potential for massive bleeding and postoperative complications. With the realization of the complexity and variability
of the internal piping structure of the hepatobiliary system,
hepatobiliary surgery has become recognized as a difcult
and important discipline within the eld of general surgery.
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978- 981- 33- 6769- 2_6) contains supplementary material, which is available to authorized users.
S. Bao · J. Pan
South China Normal University, Guangzhou, China
X. Chang
Panyu District Hospital of Traditional Chinese Medicine,
Guangzhou, China
D. Wu
Fourth Afliated Hospital of Guangxi Medical University,
Liuzhou, China
C. Fang (
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
*)
Many unsolved problems remain, and involve the development of clinical hepatobiliary anatomy, the updating of medical equipment, and the improvement of the surgeon’s
surgical skills. Virtual reality (VR), which has been applied,
researched, and developed in the medical eld in recent
years, maybe one of the technical means to solve these
problems.
VR, which refers to the use of computer technology and
hardware devices to realize a virtual illusion that can be
experienced through vision, hearing, touch, or smell, includes
not only hardware conguration, but also software and hardware coordination and man–machine interfaces. VR has
characteristics such as immersion, interaction, and imagination (three Is).
VR is a new practical technology involving many disciplines. It integrates advanced computer technology, sensing
and measurement technology, simulation technology, and
microelectronics technology. In computer technology, it is
mainly dependent on computer graphics, articial intelligence, network technology, man–machine interface technology, and computer simulation technology. The development
of these related technologies has led to the progress of VR
and also promoted its full application in a series of elds
such as education, medicine, entertainment, science and
technology, industrial manufacturing, construction, and
commerce. The successful development of the National
Library of Medicine’s Visible Human Project (VHP) in the
United States has opened the door for computer image processing and VR to enter medicine and the project has promoted the application and development of VR in the medical
eld.
Virtual surgical instruments are an essential part of the
virtual surgery system. By using virtual surgical instruments
with tactile and visual feedback, users can perform various
preoperative simulations and operation procedural exercises.
There are various surgical instruments in abdominal surgery,
such as the scalpel, electric hook, suture needle, surgical
scissors, and vascular forceps. The diversity and complexity
of the operation for these instruments have a direct impact on
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
C. Fang, W. Y. Lau (eds.), Biliary Tract Surgery, https://doi.org/10.1007/978-981-33-6769-2_6
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S. Bao et al.
the delity and real-time capabilities of the virtual surgery
system.
To provide the operator with a truly immersive operational experience, it is necessary to combine the graphical
display with the tactile display of the virtual surgical system.
When people interact with the outside environment, they
mainly perceive the characteristics of the environment
through the sensory channels such as vision, touch, and hearing. The human brain processes the information and gives
instructions to the arms to act on the environment. As a surgeon, it is essential to perceive and operate the external environment by hand. In actual surgery, the judgment and
operation of the surgeon are mainly dependent on the sense
of touch. Tactile sensation is a general term for mechanical
stimuli such as contact, sliding, and pressure. Force feedback
is a crucial tactile channel that allows the user to perceive the
weight of an object and its resistance to force. The close coupling of visual feedback, tactile feedback, and 3D spatial
sensation allows the operator to realistically feel the changes
and reaction forces generated by the organ tissue during the
operation of the virtual surgical instrument. Only in this way
can the virtual surgical system be of practical signicance.
The simulated surgical system in China started relatively
late. There is little investment in research of the virtual surgery systems with powered haptic feedback, especially in the
simulation of the liver and other soft tissues. For example,
the 3-Dimensional Medical Image Processing and Analyzing
System (3DMed) developed by the Chinese Academy of
Sciences lacks force feedback; the simulation environment is
simple, the surgical instruments are not developed, and the
procedure is complicated; the clinical surgeon must possess
strong computing skills to operate the 3DMed system (Tian
etal. 2008). The National Digital Manufacturing Technology
Center of Shanghai Jiao Tong University has developed a
multifunctional virtual surgical instrument that can operate
scalpels, surgical scissors, and surgical forceps, but it does
not possess the force feedback function. Only by combining
visual feedback and tactile feedback can the operator’s
immersion be truly improved, and the utility of virtual surgery be achieved.
6.1.1 Virtual Anatomy
hensive observation, measurement, and study of anatomical
structure. Bernard Pesser and his team at the University
Hospital Eppendorf, Hamburg enhanced VOXEL-MAN
using VHP datasets (Pesser etal. 2001). In China, a group
led by Professor Fang Chihua used the VCH-F1 liver data to
study the virtual liver biliary tract (Fang Chihua etal. 2005).
The reconstructed 3D liver model can not only help to
observe the target through the enlargement, reduction, and
rotation of the stereo image, but also can vary the color and
transparency for various tissues to display liver structures
individually or in combination.
6.1.2 Surgical Simulation
Surgical simulation refers to the simulation of a surgical process on a “virtual human body or organ” using virtual surgical instruments (scalpel, hemostatic forceps, etc.) in a virtual
environment on a computer. This technology is also known
as computer-assisted/aided surgery (CAS) and image-guided
surgery (IGS). Surgical simulation is an essential application
of virtual reality in the eld of medicine and has become a
hot topic in recent years. In order to set up a virtual surgical
system, it is necessary to reconstruct the 3D geometric model
of human tissues and organs. The physical model, the
dynamic model, the deformation model, and the nite element model are constructed using the geometric model with
the knowledge of biology and mechanics.
6.1.2.1 Characteristics ofVR Surgical Simulation
System
• Reality Accurate and detailed description of patients’
organs as well as the shape, location, and deformation of
the lesion.
• Real-time The ability to process data and display results
in real time.
• Accuracy Accurate description of the internal organ
structure.
• Manipulation Simulations of organ manipulation by
hand or other medical devices in a 3D virtual space, such
as pushing, pulling, pressing, and cutting.
• Perception Ability to receive and process specic
feedback.
The Atlas of Human Anatomy has always been the primary
tool for studying and identifying human anatomy. A traditional atlas of human anatomy is mostly illustrations depicted
in 3D or pictures of actual anatomical structures. The atlas of
digital 3D human anatomy established by the application of
virtual reality technology, as a “virtual human” digitized
dataset, visualizes the human body structural image information, as obtained by modern medical imaging equipment. It
has two advantages: accurate location in space, and compre-
6.1.2.2 Signicance ofEstablishing aSurgical
Simulation System
Preoperative Planning andRehearsal
The system can help to develop surgical planning by using
patient examination data. Through continuously targeted
rehearsal, the operation plan can be improved to establish the
best operation path, so as to reduce unnecessary damage to
the healthy tissues. Thus, the accuracy of the operation
6 Virtual Surgical Instruments andSurgical Simulation
133
localization ensures an increased success rate and reduction
of surgical complications. Moreover, the guidance of the
expert surgical system based on expert experience, can be
obtained to improve surgical skills.
Intraoperative Navigation andMonitoring
Surgical robots (such as Aesop and Da Vinci) have been
clinically used in surgical operations, especially in neurosurgery and cardiovascular surgery. By using image information provided before surgery such as from X-ray,
Computed Tomography (CT), Magnetic Resonance Imaging
(MRI), Digital Subtraction Angiography (DSA), CT
Angiography (CTA), MR Angiography (MRA), and Positron
Emission Tomography (PET), as well as medical robots; the
real-time images during operation can be registered and
located to guide the surgery (such as radiofrequency ablation, interventional therapy, and vascular embolization). It is
of great signicance for improving the accuracy of surgery,
reducing surgical injury, and improving the success rate of
surgery.
Surgery Teaching andTraining
With “virtual surgery,” medical students or doctors can learn
surgical skills and even practice the procedure without time
and space constraints. They can also be guided by an expert
operating system based on expert experience to improve surgical skills and shorten the time to competency.
Organ Transplantation andReceptor Matching
Model
Virtual surgery can help surgeons accurately measure the
size and shape of organ transplants (such as liver transplantation, especially living donor liver transplantation) before
organ transplantation based on a 3D reconstruction of the
image data and evaluate the matching degree of their
morphology.
Improved Doctor–Patient Relationship
A large number of doctor–patient relationships are harmed
by a lack of communication between doctors and patients,
and a lack of in-depth understanding by patients and their
families. Virtual surgery can bridge the gap between doctors
and patients. With the help of this technology, doctors can
easily introduce the patients’ condition, surgical treatment
plan, and the procedure of the operation in detail, to achieve
an excellent doctor–patient relationship with full mutual
understanding and trust.
Reduced Surgical Costs
Modern surgical testing systems are expensive and costly.
Since virtual surgery is not restricted by surgical equipment,
it can reduce the blindness of surgical exploration thereby
reducing the degree of bodily injury; consequently, shorten-
ing the recovery cycle of patients, and reducing the expense
to patients and hospitals.
Construction ofCustomized Prosthetic Fitting
Models
Virtual surgery can design implants (prostheses). For example, a computer can help doctors accurately measure the size
and shape of a hip bone using non-destructive 3D imaging
prior to the hip replacement surgery, and customize the prosthetic implants, which can signicantly reduce the proportion of reoperation due to size failure.
Remote Intervention
Virtual surgery and remote intervention will enable surgeons
in the operating room to get interactive consultations with
remote experts in real time. The interactive tools allow the
consultant to project the target on the patient to help guide
the surgeon’s operation or to help manipulate the instrument
through remote control. With remote intervention the skills
of experts can be accessed regardless of space or distance.
6.1.2.3 Current Status ofSurgical Simulation
The rapid development of modern surgery is closely related
to the application of modern scientic and technological
means in medicine. Höhne et al. (2001) reconstructed the
human body model utilizing data from the Visible Human
Project (VHP) dataset, and then, they operated on the reconstructed model with a simulated scalpel; “real” visual and
tactile effects were produced using the particular device
PHANTOM.The virtual intracranial visualization and navigation system developed by Kockro etal. (2000) used a virtual environment constructed by 3D reconstruction of
patients’ imaging data obtained before operation (CT, MRI,
MRA) to plan and simulate the operation of brain tumor and
intracranial vascular malformation. Soler etal. (2000) used
interactive visualization and virtual cutting tools to perform
virtual hepatectomy on the 3D HCT (spiral CT) liver model
according to the user-dened cutting plane. All of these protocols signicantly improved the surgical effect.
With the continuous progress of computer technology and
image processing technology, simulation reality technology
has become a rapidly developing technical eld in recent
years, with increasingly broad application. Virtual simulation technology has been widely used in biliary diseases such
as hilar cholangiocarcinoma, ampullary tumor, extrahepatic
cholecystolithiasis, choledocholithotomy, individualized
cholecystolithiasis and choledocholithotomy, and left hepatectomy. Surgeons can make full use of simulated surgery to
practice repeatedly, familiarize themselves with the surgical
process, improve surgical skills, and shorten their time to
competency. They can also use it to carry out new operations
and to update the existing knowledge of operations and strive
for excellence.