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10 Digital Surgical Diagnosis andManagement ofCholecystolithiasis
Fig. 10.9 Gallbladder bed
cut open
217
Fig. 10.10 Procedure of
gallbladder bed incision
218
Fig. 10.11 Gallbladder
resection line
N. Xiang et al.
Fig. 10.12 Remove
gallbladder
10 Digital Surgical Diagnosis andManagement ofCholecystolithiasis
Fig. 10.13 Suture the cystic
duct
219
Fig. 10.14 Suture line of the
cystic duct
220
N. Xiang et al.
• In complicated portal hypertension, the hepatic portal
area is complicated by blood vessels and there are many
pathological variations of vessels. The thin varicose vein
wall is easily damaged, causing bleeding.
All of these above factors may increase iatrogenic injury
and even lead to life-threatening intraoperative bleeding that
is difcult to control.
For the above-mentioned laparoscopic cholecystectomy,
3D visualization technology has a unique guiding advantage
over traditional imaging technology. Through preoperative
study of 3D visualization on patients with cholecystolithiasis:
• The shape of the gallbladder, the shape and distribution of
gallstones, and the anatomical relationship between the
gallbladder and its surrounding organs are stereoscopically displayed.
• The anatomical relationship of the anterior and posterior
triangle of the gallbladder are clearly displayed and the
ow of the blood vessels is observed.
• The variation of the bile duct, gallbladder neck duct, gallbladder artery, and the right hepatic artery was evaluated.
• In patients with choledocholithiasis and Mirizzi syndrome,
the course of the extrahepatic bile duct, and its dilatation or
stenosis is demonstrated in three dimensions.
• The gallbladder bed with or without the variability of the
hepatic vein branch or portal vein exposure is individually
displayed in order to prevent accidental bleeding during
the operation.
On this basis, we can also use the construction of three-
dimensional visualization platforms for virtual surgery,
and change the traditional methods of diagnosis and treatment, so that clinicians can obtain more intuitive and realistic clinical data so as to formulate detailed and rational
treatment plans for patients and optimize the operation
method. It also provides the doctors with opportunities for
rehearsal repeatedly before the operation, to increase their
prociency and cooperation, thus speeding up the progress
of the operation, increasing the probability of success, and
reducing complications. The visualization of surgery can
also change the traditional medical teaching model; that is,
it no longer relies on the traditional method of learning surgery solely by carbon pen, hand-drawn line, and anatomical
atlas. Instead, it relies on three-dimensional images from
real patients as the object of operation research. It provides
a real and intuitive operation process for classroom teaching, as well as for the operation teaching of graduate students, intern doctors, and advanced students; increasing the
opportunity to practice, improving learning efciency, and
shortening the learning curve.
References
Bortoff GA, Chen MY, Ott DJ, Wolfman NT, Routh WD.Gallbladder
stones: imaging and intervention. Radiographics. 2000;20(3):
751–66.
Chuah PS, Curtis J, Misra N, Hikmat D, Chawla S.Pictorial review:
the pearls and pitfalls of the radiological manifestations of gallstone ileus. Abdom Radiol (NY). 2017;42(4):1169–75. https://doi.
org/10.1007/s00261- 016- 0996- 0.
Fan Y, Xiang N, Wang L. Three-dimensional laparoscopic cholecys-
tectomy: a case report and literature review. J South Med Univ.
2013;33(12):1856–7.
Hwang H, Marsh I, Doyle J.Does ultrasonography accurately diag-
nose acute cholecystitis? Improving diagnostic accuracy based on a
review at a regional hospital. Can J Surg. 2014;57(3):162–8.
Zeman RK. Cholelithiasis and cholecystitis. In: Gore RM, Levine
MS, Laufer I, editors. Textbook of gastrointestinal radiology.
Philadelphia, PA: Saunders; 1994. p.1636–74.
Zeng N, Fang C, Yang J, etal. Application of three-dimensional laparo-
scopic cholecystectomy for complicated gallstone disease. J South
Med Univ. 2016 Jan;36(1):145–7.
Digital Surgical Diagnosis
andManagement ofExtrahepatic
Cholelithiasis
YunqiangTang, XuChang, andChihuaFang
11
11.1 Introduction
Extrahepatic cholelithiasis is a frequently occurring biliary
tract disease in China. It commonly manifests by obstruction
of the common bile duct and leads to acute cholangitis; if not
treated in a timely manner, it will cause acute obstructive
suppurative cholangitis or acute severe cholangitis, eventually progressing into shock and loss of consciousness. The
condition is dangerous, with a high mortality rate. Surgical
intervention remains the primary therapy and the only effective treatment for extrahepatic cholelithiasis; however, reoperation on the extrahepatic bile duct is one of the most
frequent reoperations in abdominal surgery. Reoperation following biliary tract surgery is more complicated than the initial procedure, and the scope of surgery is wider. It not only
increases the suffering and nancial burden of patients but
also easily leads to medical disputes. The leading causes of
reoperation include residual and/or recurrence of bile duct
stones, as well as bile duct injury and stenosis of various
etiologies. In addition to the inuence of many factors, such
as the condition of the disease, the level of technology, the
condition of the equipment, insufcient preoperative understanding of the anatomical abnormalities such as the site, and
quantity of biliary tract stones; the extent of stenosis and
dilatation, as well as the distribution of blood vessels, are
also relevant.
In recent years, there have been considerable efforts made
toward promoting the development of digital surgical treatment and management of extrahepatic cholelithiasis. Peng
Weibin etal. (2005) used MSCT virtual endoscopy to detect
Y. Tang
Afliated Cancer Hospital and Institute of Guangzhou Medical
University, Guangzhou, China
X. Chang
Panyu District Hospital of Traditional Chinese Medicine,
Guangzhou, China
C. Fang (
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
*)
biliary calculus, and they believed that endoscopy could
accurately display the 3D dynamics of the stones; the size
and location of stones observed at any angle in 3D space
were consistent with the ndings of ultrasound, transverse
axis CT or surgery. Fasel etal. (1996, 2010) and Fasel and
Schenk (2013) reconstructed the main branches of the liver,
gallbladder, intrahepatic vein system, and intrahepatic and
extrahepatic biliary system using the VHP dataset. The
model was used to simulate the minimally invasive and
endoscopic procedures for the surgical treatment of biliary
diseases. Other scholars have carried out researches on 3D
reconstruction of hepatobiliary system images. For example,
Giadás etal. (2002) evaluated the role of helical computer
tomographic cholangiography (HCT-C) in the visualization
of the biliary tract. Using data of intrahepatic and extrahepatic cholelithiasis obtained by 64-slice spiral CT scan, Fang
etal. carried out a research on 3D visualization and surgery
simulation, by which surgical planning could be optimized
and preoperative rehearsal be performed, thereby improving
surgical safety and reduce complications (Fan etal. 2007).
Digital surgery has been developing at an amazing rate and
increasingly being been used to guide the diagnosis and
management of extrahepatic cholelithiasis.
11.2 3D Modelling ofExtrahepatic
Cholelithiasis
Extrahepatic cholelithiasis refers to stones located in the
common bile duct, common hepatic duct, left hepatic duct,
and right hepatic duct, of which choledocholithiasis accounts
for the majority. B-ultrasound can detect the intrahepatic bile
duct dilatation and intracavitary stones with good sensitivity.
At the same time, it can show the pathological changes in the
liver parenchyma and is the rst choice for the examination
of hepatolithiasis. However, B-ultrasound cannot show the
complete picture of the biliary system, especially the stricture of the bile duct, the results are easily affected by the
subjective experience of the examiner, and there has a
© 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_11
221
222
ab
Y. Tang et al.
recognized rate of misdiagnosis. Therefore, the results of
B-ultrasound cannot solely be used as the basis for surgery.
CT can show the distribution of hepatolithiasis, the systemic
images of the bile duct and hepatic parenchyma lesions, and
has a signicant value in the diagnosis of hepatolithiasis.
Stereoscopic conformation of the intrahepatic bile duct system and the distribution of intrahepatic stones can be obtained
by observing the CT photographs of each level systematically. MRCP is a noninvasive method for the diagnosis of the
biliary tract. It can display an intrahepatic bile duct tree in
various directions. Combined with the original image, it can
accurately judge the distribution of intrahepatic stones,
lesions of the bile duct system, and hepatic parenchyma. It is
superior to CT and direct biliary tract imaging in the diagnosis of hepatolithiasis. PTC and ERCP can clearly show the
whole picture of the bile duct system and provide an essential basis for surgical treatment. However, PTC and ERCP
cannot show lesions outside the bile duct. Moreover, both, as
invasive examination methods, may cause some severe complications. Thus, their indications should be strictly
controlled.
With the development of digital surgery for extrahepatic
cholelithiasis, a three-dimensional biliary tract model can be
established by using a 64-row spiral CT with high temporal
and spatial resolution and using advanced equipment with
powerful data processing ability. It is more favorable for preoperative evaluation and optimization of surgical options.
11.2.1 Image Data ofCholedocholithiasis
Scanned by 64-Slice Spiral CT
The methods are the same as those mentioned above.
Traditional two-dimensional CT images (Fig.11.1) are converted to BMP format by DICOM viewer software with
415×303×32b specication and an 832MB data set size
(Fig. 11.2). The contour of the liver is precise, the crosssection tube contrast agent is well lled, the various vascular
tubes are clear, and the stones are located about
1.5cm ×1.5cm in the lower part of the common bile duct
(Figs.11.1b and 11.2d).
11.2.2 Image Registration
The specic method is the same as the above described
(Fig.11.2a, b).
11.2.3 Image Segmentation and3D Modelling
The BMP data containing choledocholithiasis were imported
into the medical image processing system to complete automatic image segmentation and 3D reconstruction (Fig.11.3).
The model was further processed by introducing the
FreeForm Modeling System. After smoothing, and removing
Fig. 11.1 2D CT image. (a) CT image of original gallbladder and common bile duct dilatation; (b) CT image of calculi in the lower common bile
duct
11 Digital Surgical Diagnosis andManagement ofExtrahepatic Cholelithiasis
a
223
b
Fig. 11.2 DICOM view and its image converted to BMP format. (a) ICOM viewer reads CT images; (b) Convert to BMP format in DICOM
viewer and save; (c) BMP image of choledochal dilatation; (d) BMP image of calculi in the lower segment of common bile duct
224
cd
Fig. 11.2 (continued)
Y. Tang et al.
the layering and noise, a three-dimensional model with realistic conguration and strong stereoscopic effect can be
obtained. The abdominal aorta and its branches are clearly
displayed in the arterial system, and the hepatic artery and
the left hepatic artery, the right hepatic artery, and its subordinate branches are also clearly displayed (Fig.11.4a). The
right branch of the hepatic vein and the main trunk of the
middle hepatic vein show well in the venous system, and the
branches of the hepatic vein can also be clearly displayed
under normal conditions. Because there are left intrahepatic
bile duct stones with extrahepatic bile duct stones and left
liver atrophy, the model can only identify the third-grade
hepatic vein of the right liver with the naked eye, and not the
left hepatic vein, which is consistent with the atrophy of the
left liver seen in the original image (Fig.11.4c). The portal
vein was well displayed, almost reaching the ve branches of
the portal vein and the splenic vein (Fig.11.4b), and the hepatobiliary system model was consistent with the original
structure, and when the transparency of the biliary tract was
0.25, the stones could be seen (Fig.11.4d, e).
11.3 Virtual Surgery forExtrahepatic
Cholelithiasis
As mentioned above, a 64-slice spiral CT can be utilized to
perform visualization research of the biliary tract system and
to establish a three-dimension bile duct model.
Simultaneously, visual simulation surgery can be carried out,
which makes the preoperative evaluation and selection of a
surgical plan more reasonable.
11.3.1 Secondary Development andVisual
Simulation ofVirtual Surgical
Instruments
The SLT format of choledocholithiasis and the models of
liver, bile, pancreas, and spleen were introduced into the
FreeForm Modeling System to be processed to smooth and
remove the layer and noise. However, because the system
does not have the virtual surgical instruments, the secondary
development of the surgical instruments is carried out using
the GHOST SDK software, and the molds of the secondarily
developed instruments and devices, such as T-shaped tubes,
are imported into the system to perform visual simulation of
choledocholithotomy and T-tube drainage.
The specic steps are as follows:
• Step 1 When the transparency of the liver is 1, the three-
dimensional model of the liver and gallbladder is displayed (Fig.11.5). When the transparency of the liver is
0.5, the internal structure of the liver is shown (Fig.11.6).
When the transparency of the liver and gallbladder is 0.5,
the stones at the lower end of the common bile duct are
shown (Fig.11.7). When the transparency of the liver and
bile duct is 1 and 0.5, respectively, the black stones at the
lower end of the common bile duct are visible (Fig.11.8).
• Step 2 Activate the biliary system, introduce a virtual
scalpel, and cut the lower end of the common bile duct
(Fig.11.9).
• Step 3 Introduce lithotripsy forceps to perform the pro-
cess of removing the stones at the lower end of the common bile duct (Fig.11.10a, b, c).
11 Digital Surgical Diagnosis andManagement ofExtrahepatic Cholelithiasis
a
225
b
Fig. 11.3 Image segmentation and 3D reconstruction. (a) Import BMP
data in MIPS for segmentation; (b) 3D reconstruction in MIPS; (c) segmentation of the liver; (d) segmentation of gallbladder and common
bile duct; (e) segmentation of common bile duct stones; (f) segmentation of the arterial system; (g) segmentation of hepatic veins; (h) segmentation of portal vein
226
Y. Tang et al.
c
d
Fig. 11.3 (continued)