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technical essentials of surgical treatment of gallbladder diseases, biliary stones, and biliary
tumors. The content is rich and detailed, the production is smooth and exquisite, and the book
has high academic value. This monograph can be used not only for doctors at all levels in general surgery, hepatobiliary surgery, imaging, and biomedical engineering clinical directions but
also for graduate students and undergraduates to understand the application of digital medicine
in clinical surgery. This book can help them understand the rich connotation of digital medicine in clinical surgery, enlighten their innovative thinking, and help young scholars to learn
and progress in today’s rapidly changing era of biological intelligence information.
In view of the fact that digital medicine has become one of the future development directions of general surgery in China, I sincerely recommend this book to readers, and I wish Prof.
Fang’s team new achievements in the march toward digitalized hepatobiliary and pancreatic
surgery.
YupeiZhao
Academician of the Chinese Academy of Sciences
Professor of Surgery
Peking Union Medical College Hospital, Beijing, China
October 19, 2020
Foreword IV
Preface
In the new era of digital medicine, the application of new technologies represented by 3D
printing, big data, articial intelligence, radiomics, and photoacoustic imaging of tumor
boundary ushered in the publication of this book.
There is an old Chinese proverb, “when you drink water, think about the source.” In 2002,
the author started the research on segmentation, registration, and 3D reconstruction of the
image data of the liver, biliary tract, and pancreas under the guidance of Academician Shizhen
Zhong, the famous clinical anatomist. It has been 18 years. During this period, our team has
(1) developed a 3D visualization system for abdominal medical images (software copyright
2008SR18798) and a virtual surgical instrument simulation system (software copyright
2008SR18799). Both have certications from China’s National Medical Products
Administration. (2) Put forward the theory of 3D visualization, and innovatively built the core
technology and system for 3D visualization and accurate diagnosis and management of complex hepatobiliary and pancreatic diseases, including 3D visualization and precision diagnosis
and treatment platforms for complex liver cancer, central liver cancer, hepatolithiasis, hilar
cholangiocarcinoma, and pancreatic cancer, respectively. (3) Compiled and published the rst
set of internationally applicable specications, operating guidelines, and consensus recommendations. (4) Proposed and established the concept of digital intelligence diagnosis and
treatment technology and utilized this technology primarily for the diagnosis and management
of liver cancer, which was published in The Lancet’s EBioMedicine. This technology is based
on 3D visualization, combined with 3D printing, virtual reality, augmented reality, mixed reality, uorescent navigation, real-time image fusion, and photoacoustic imaging for precise diagnosis and treatment of primary liver cancer. (5) Developed a novel laparoscopic hepatectomy
navigation system, the LHNS, to address the issue of intraoperative multimodal non-rigid registration of the liver. (6) Pioneered the use of digital intelligent technology to navigate anatomical, functional, and radical hepatic resection for primary liver cancer, using
computer-assisted indocyanine green (ICG) uorescent imaging. (7) Achieved integration of
early diagnosis and treatment of experimental liver cancer by combining photoacoustic imaging and target-specic molecular probes and pushed detection and management of liver cancer
from morphological to molecular and cellular levels. In addition, under the funding of the
National Science and Academic Monograph Publishing Fund, we published the rst international series of Digital Hepatic Surgery, Digital Pancreatic Surgery, and this book. The
research results above have won two rst prizes and one second prize of Guangdong Science
and Technology Progress Awards in 2010, 2019, and 2015, respectively, and the ChinaIndustry- University-Research Collaboration Innovation Award in 2014. Digital medical technology was born in Guangdong, extended and developed across China, and has been promoted
and applied in more than 500 hospitals.
“Only comparison can distinguish.” Based on the visibility of CT and MRI, 3D visualization technology realizes clearer and more accurate views. It has improved the accuracy of
disease diagnosis, effectively reduced the risks and complications of surgery, and truly changed
the past “crossing the river by feeling the stones” and realizing the current “crossing the river
by watching the stones.” This is the greatest contribution that 3D visualization technology has
made to the diagnosis of human surgical diseases.
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xiv
“If you don’t have a garden, how can you know how spring is like.” The biliary system is a
very important organ of the human body. The upper part connects to the liver and the lower part
to the pancreas. It has its unique anatomical position and functional characteristics. Especially
the biliary tract tree, once you step into it, it is like entering a “maze.” Therefore, biliary surgery faces great challenges. The breakthrough point of biliary tract surgery is to grasp the
complexity and variability of liver vascular structure, especially the biliary system. Although
the advancement of modern imaging has promoted the development of hepatobiliary surgery,
patients with biliary diseases, such as hepatolithiasis and hilar cholangiocarcinoma, experience a long course of chronic cholangitis and chronic obstruction of the biliary tract before
they are clear of symptoms. The biliary structure can be twisted, deformed, expanded, or narrowed, and pathophysiological changes such as necrosis, hyperplasia, brosis, atrophy, or
hypertrophy can occur in the adjacent liver tissue, which may increase the difculty in identifying the very complex intrahepatic bile duct system and add uncertainty to the preoperative
assessment of blood vessels, bile ducts, and their relationship with the lesion. Even modern
imaging techniques sometimes seem pale and weak. We feel deeply that the 3D visualization
of biliary surgery disease is far more difcult than 3D visualization of the liver and pancreas.
“The source of living water is full everywhere, and the east wind and the owers will
change with the times.” It is an important task for a scientist to determine how to use digital
medical technology to guide the precise diagnosis and treatment of biliary surgery diseases.
Closely focusing on this key issue, with clinical needs as the driving purpose, and from a clinical perspective, 15 years ago, we innovatively pooled experts in the elds of hepatobiliary
surgery, imaging, anatomy, computer image processing, physics, and molecular imaging to
carry out research. Complex hepatolithiasis and hilar cholangiocarcinoma are regarded as our
main goals. Serendipitously, it has been found that the 3D visualization model of hepatolithiasis can clearly show the size, location, and shape of the stone; the location, length, and degree
of the stenosis of the bile duct; and the relationship between the stone and the blood vessel. It
has provided a solid foundation for subsequent preoperative planning and selection of surgical
methods. The 3D visualization model of hilar cholangiocarcinoma accurately displays the
relationship between the location of cholangiocarcinoma and the portal vein and hepatic artery,
and accurately evaluates the positions of P and U points (the limit point of bile duct separation)
enabling the classication of hilar cholangiocarcinoma and whether it can be resected. The
result is unparalleled by other imaging inspection methods. Firstly, we have achieved a series
of new methods of targeting lithotripsy guided by three-dimensional visualization, which overcomes the problem of high residual stone rate after surgery. Secondly, we have proposed the
concept of “digital minimally invasive technology” and applied it to the practice diagnosis and
treatment of hepatobiliary stones, realizing the digitalization of minimally invasive diagnosis
and treatment of biliary surgical diseases. Thirdly, we have established the 3D visualized clinical classication of hilar cholangiocarcinoma, which truly achieved “crossing the river by
watching the stones.” Fourthly, we achieved anatomical, functional, and radical hepatic resection for hilar cholangiocarcinoma by using 3D visual morphological precision assessment
technology with the indocyanine green uorescent molecular imaging diagnostic technology.
“One leaf in the boat will bring spring scenery to the south of the Yangtze River.” This book
was reviewed by Academician Shizhen Zhong, edited by Prof. Chihua Fang and Academician
Wan Yee Lau, and prefaced by Academicians Mengchao Wu, Jieshou Li, Shizhen Zhong, and
Yupei Zhao. The key chapters and sections of this monograph have been integrated and compiled by media such as paper, animation, 3D, and surgical videos. During the reading process,
the reader can click on the relevant media to see the exquisite 3D pictures and surgical videos
which are faithful to the patient’s disease.
“Generally, the roots are in the soil, and each will wait for the time.” Through persistent
clinical observations and tireless work day and night, our team adheres to scientic and realistic research and humbly sought advice; nally, we completed the publication of this book. This
book is a successor to Digital Liver Surgery and Digital Pancreatic Surgery, another key
research monograph on digital medicine. The three sister monographs are the result of research
Preface
Preface
xv
completed under the funding of the “11th Five-Year Plan” and “12th Five-Year Plan” national
“863” project, the “13th Five-Year Plan” National Digital Diagnosis and Treatment Project,
and the National Natural Science Foundation of China. “Leave ingenuity alone to pass the
ages”—this set of research results using modern high-tech technology, successfully applied to
clinical practice formulation and planning, has strong cutting-edge, scientic, practical, and
clinical guidance value. This book is not only suitable for reading by hepatobiliary and pancreatic surgery workers but also for undergraduates and graduate students to read, reference, and
use, which is benecial to accelerate the growth of surgeons.
Guangzhou, China ChihuaFang
October 20, 2020
Acknowledgments
The authors are grateful to the contributors for their work of editing the Chinese version of this
book and collecting pictures, videos, and ow charts. Also, we would like to express our heartfelt gratitude to John Clarke, the British foreign language teacher of Southern Medical
University, for his contribution to proofreading and copyediting of this book.
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Contents
1 Applied Anatomy of the Biliary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Jun Ouyang, Chihua Fang, and Min Hu
2 Application of Multi-slice Spiral CT and MRI in Biliary Surgery . . . . . . . . . . . . . 15
Suisheng Zheng, Xijun Gong, Xuchang Zhang, Yangguang Yuan,
Xinming Li, and Chihua Fang
3 Imaging of Common Biliary Tract Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Xianyue Quan, Shuping Qian, Zhendong Qi, Jingjing Huang,
Liying Han, and Chihua Fang
4 Introduction to 3D Visualization of Abdominal CT Images . . . . . . . . . . . . . . . . . . 101
Susu Bao, Fengping Peng, and Chihua Fang
5 Application of 3D Printing Technology in Hepato-Biliary-Pancreatic Surgery . . 117
Chihua Fang and Zhaoshan Fang
6 Virtual Surgical Instruments and Surgical Simulation . . . . . . . . . . . . . . . . . . . . . . 131
Susu Bao, Jiahui Pan, Xu Chang, Dongbo Wu, and Chihua Fang
7 Application of Indocyanine Green Fluorescent Imaging in Biliary Surgery . . . . . 161
Chihua Fang and Wen Zhu
8 Application of Endoscopic Techniques in Biliary Tract Surgery . . . . . . . . . . . . . . 173
Zhaohui Tang and Chihua Fang
9 Application of 3D Visualization for Blood Supply of Extrahepatic Bile Ducts . . .185
Chihua Fang, Jian Yang, and Xu Chang
10 Digital Surgical Diagnosis and Management of Cholecystolithiasis . . . . . . . . . . .205
Nan Xiang, Songsheng He, and Chihua Fang
11 Digital Surgical Diagnosis and Management of Extrahepatic Cholelithiasis . . . . 221
Yunqiang Tang, Xu Chang, and Chihua Fang
12 Digital Surgical Diagnosis and Management of Hepatolithiasis . . . . . . . . . . . . . . . 239
Qiping Lu, Jian Yang, Ping Wang, Jun Liu, Yingfang Fan, and Chihua Fang
13 Digital Surgical Diagnosis and Management of Biliary Dilatation . . . . . . . . . . . . 311
Jian Yang, Haoyu Hu, and Chihua Fang
14 3D Visual Diagnosis and Management of Bile Duct Injuries . . . . . . . . . . . . . . . . . 321
Ning Zeng, Silve Zeng, Jian Wang, Jiayan Yan, and Chihua Fang
xix
xx
15 Digital Surgical Diagnosis and Treatment of Gallbladder Cancer . . . . . . . . . . . . . 337
Yingbin Liu, Haibin Liang, Jianming Wang, Yan Liu, and Chihua Fang
16 Digital Diagnosis and Management of Cholangiocarcinoma . . . . . . . . . . . . . . . . . 363
Feng Shen, Kui Wang, Qifei Zou, Ning Zeng, Xiangcheng Li,
and Chihua Fang
17 Application of 3D Visualization Technology in Perihilar Surgery . . . . . . . . . . . . . 421
Jian Wang, Jiayan Yan, and Chihua Fang
Contents
Editors and Contributors
Deputy Editors
QipingLu General Hospital of Central Theater Command, Wuhan, China
XianyueQuan Zhujiang Hospital, Southern Medical University, Guangzhou, China
JunOuyang Department of Anatomy, Southern Medical University, Guangzhou, China
Contributors
SusuBao South China Normal University, Guangzhou, China
WeiCai Zhujiang Hospital, Southern Medical University, Guangzhou, China
XuChang Panyu District Hospital of Traditional Chinese Medicine, Guangzhou, China
YingfangFan Zhujiang Hospital, Southern Medical University, Guangzhou, China
ChihuaFang Zhujiang Hospital, Southern Medical University, Guangzhou, China
Zhaoshan Fang The Fifth Afliated Hospital of Guangxi Medical University, Nanning,
China
XijunGong The Second Afliated Hospital of Anhui Medical University, Anhui, China
LiyingHan Zhujiang Hospital, Southern Medical University, Guangzhou, China
SongshengHe Zhujiang Hospital, Southern Medical University, Guangzhou, China
HaoyuHu Zhujiang Hospital, Southern Medical University, Guangzhou, China
MinHu Zhujiang Hospital, Southern Medical University, Guangzhou, China
JingjingHuang Zhujiang Hospital, Southern Medical University, Guangzhou, China
YaohuanHuang Zhujiang Hospital, Southern Medical University, Guangzhou, China
WanYeeLau Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong,
China
XiangchengLi The First Afliated Hospital of Nanjing Medical University, Nanjing, China
XinmingLi Zhujiang Hospital, Southern Medical University, Guangzhou, China
HaibinLiang Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai,
China
Yan Liu Tongji Hospital Afliated to Tongji Medical College, Huazhong University of
Science and Technology, Wuhan, China
xxi
xxii
YingbinLiu Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai,
China
JiahuiPan South China Normal University, Guangzhou, China
FengpingPeng South China Normal University, Guangzhou, China
ZhendongQi Zhujiang Hospital, Southern Medical University, Guangzhou, China
ShupingQian Zhujiang Hospital, Southern Medical University, Guangzhou, China
Feng Shen Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai,
China
YunqiangTang Afliated Cancer Hospital and Institute of Guangzhou Medical University,
Guangzhou, China
ZhaohuiTang Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai,
China
Jian Wang Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai,
China
JianmingWang Tongji Hospital Afliated to Tongji Medical College, Huazhong University
of Science and Technology, Wuhan, China
Kui Wang Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai,
China
Editors and Contributors
PingWang First Afliated Hospital, Guangzhou Medical University, Guangzhou, China
DongboWu Fourth Afliated Hospital of Guangxi Medical University, Liuzhou, China
NanXiang Zhujiang Hospital, Southern Medical University, Guangzhou, China
Jiayan Yan Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai,
China
JianYang Zhujiang Hospital, Southern Medical University, Guangzhou, China
JunyingYang Zhujiang Hospital, Southern Medical University, Guangzhou, China
YangguangYuan Zhujiang Hospital, Southern Medical University, Guangzhou, China
NingZeng Zhujiang Hospital, Southern Medical University, Guangzhou, China
SilveZeng Zhujiang Hospital, Southern Medical University, Guangzhou, China
PengZhang Zhujiang Hospital, Southern Medical University, Guangzhou, China
XuchangZhang Zhujiang Hospital, Southern Medical University, Guangzhou, China
XingyangZhao Zhujiang Hospital, Southern Medical University, Guangzhou, China
SuishengZheng The Second Afliated Hospital of Anhui Medical University, Anhui, China
WenZhu Zhujiang Hospital, Southern Medical University, Guangzhou, China
Qifei Zou Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai,
China
Manuscripts Translation and Preparation
SaiWen Zhujiang Hospital, Southern Medical University, Guangzhou, China
Applied Anatomy oftheBiliary Tract
JunOuyang, ChihuaFang, andMinHu
1
1.1 Introduction
Since prevention of injury is of paramount importance, a
thorough familiarity with the anatomy and related research
methodologies of the biliary system is essential. The technologies developed to produce both physical and virtual
three-dimensional (3D) modelling have greatly enhanced the
learning process and contribute signicantly to patient safety.
This chapter will present:
• A detailed description of the applied anatomy of the bili-
ary system (such as associated structures and the blood
supply).
• The method of instillation of the invitro biliary tract as
well as the perfusion of the vascular cast.
• The construction steps of the digitized virtual biliary system
(liver milling, data acquisition, and 3D reconstruction).
1.2 Applied Anatomy oftheBiliary
System
The biliary system, which is subdivided into intrahepatic and
extrahepatic ducts, transports bile secreted by hepatocytes to
the duodenum. It originates from the bile capillaries in the
liver, and its terminal end joins with the pancreatic duct and
then opens into the duodenum at the major duodenal papilla.
The intrahepatic bile duct can be divided into segmental
bile ducts, sectional bile ducts, and left and right hepatic
ducts. The extrahepatic bile duct comprises left and right
hepatic ducts, common hepatic duct, gallbladder, cystic duct,
and common bile duct.
J. Ouyang
Department of Anatomy, Southern Medical University,
Guangzhou, China
C. Fang (
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
*) · M. Hu
1.2.1 Anatomy ofIntrahepatic Bile Ducts
The intrahepatic bile duct originates from the bile capillary
in the liver and then converts into the interlobular bile ducts,
segmental bile ducts, sectional bile ducts, and left and right
hepatic ducts (Fig.1.1).
The intrahepatic bile ducts run in the portal tract alongside the portal vein radicles and hepatic artery branches
(Fig.1.2), all of which are surrounded by a connective tissue
sheath (Glisson sheath).
Branches of the intrahepatic bile ducts are generally
named based on the lobes and segments of the liver. The term
“rst-order branches” refers to the left and right hepatic
ducts; “second-order branches” refers to the left medial
hepatic duct, left lateral hepatic duct, right anterior hepatic
duct, and right posterior hepatic duct; and “third-order
branches” refers to right anterior hepatic ducts, right posterior hepatic ducts, left medial hepatic ducts, and left lateral
hepatic ducts (Kogure etal. 2000).
1.2.2 Anatomy ofExtrahepatic Bile Ducts
The extrahepatic biliary system consists of the left and right
hepatic ducts, the common hepatic duct, the gallbladder, the
cystic duct, and the common bile duct (Zhong 1998).
1.2.2.1 The Left andRight Hepatic Ducts
andtheCommon Bile Duct
The common hepatic duct is formed by the junction of the
left and right hepatic ducts in the depth of the liver hilum.
The right hepatic duct usually lies alongside the right transverse groove of porta hepatis, deep in the posterior superior
part of the liver. It is thick and short, with the length ranging
from 2 to 3cm, and has an angle of about 150
mon hepatic duct. The left hepatic duct lies alongside the left
transverse groove of porta hepatis, receiving bile from the
bile canaliculi in the left caudate process. It is slender and
shallow, with the length varying from 2.5cm to 4cm and at
o
with the com-
© 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_1
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