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11 Digital Surgical Diagnosis andManagement ofExtrahepatic Cholelithiasis
237
a
b
Fig. 11.12 3D visualized simulation surgery—simulating the process of suture of bile duct and indwelling of T-tube. (a) Introduce the suture
needle to suture the common bile duct; (b) suture the common bile duct; (c) suture of the common bile duct incision
238
Y. Tang et al.
c
Fig. 11.12 (continued)
References
Fan Y, Fang C, Zhu X.Clinical application of three-dimensional imag-
ing of 64-slices spiral CT cholangiography in pathological diagno-
sis of hepatolithiasis. Chin J Dig Surg. 2007;6(6):428–32.
Fasel JH, Schenk A.Concepts for liver segment classication: neither
old ones nor new ones, but a comprehensive one. J Clin Imaging
Sci. 2013;3:48. https://doi.org/10.4103/2156- 7514.120803.
Fasel JHD, Muster M, Gailloud P, Mentha G, Terrier F. Duplicated
hepatic artery: radiologic and surgical implications. Acta Anat.
1996;157:164–8.
Fasel JH, Majno PE, Peitgen HO.Liver segments: an anatomical ratio-
nale for explaining inconsistencies with Couinaud’s eight-segment
concept. Surg Radiol Anat. 2010;32:761–5.
Giadás T, Octavio de Toledo L, Asensio M, etal. Helical CT cholan-
giography in the evaluation of the biliary tract: application to the
diagnosis of choledocholithiasis. Abdom Imaging. 2002;27:61–70.
Peng W, Chen G, Zhao L, etal. MSCT virtual endoscopy: primary clini-
cal applications in the detection of biliary calculus. J Jiangsu Univ
(Medical Edition). 2005;015(002):124–5.
Digital Surgical Diagnosis
andManagement ofHepatolithiasis
QipingLu, JianYang, PingWang, JunLiu, YingfangFan,
andChihuaFang
12
12.1 Introduction
Hepatolithiasis refers to stones that originated from the intrahepatic biliary system, which can exist alone or coexist with
extrahepatic bile duct stones. As a common biliary tract disease that is difcult to treat, hepatolithiasis is characterized
by slow progress and severe consequence. When the hepatobiliary system suffers from progressive damage caused by
diffuse stone obstruction and recurrent cholangitis, it can
lead to severe complications such as biliary cirrhosis and
portal hypertension, cholangiocarcinoma, liver failure, and
eventually to the nal stage of biliary disease. It has become
the most challenging problem in hepatobiliary surgery and
liver transplantation and is an important cause of death in
benign biliary tract diseases in China.
Since the 1950s, Professor Zhiqiang Huang has organized
domestic specialists to perform researches on the diagnosis
and management of hepatolithiasis from various perspectives. Based on the clinical and pathological studies of a
large number of cases, it is recognized that intrahepatic cholangiolithiasis is a strict intrahepatic segmental lesion. In the
pathological range, the liver tissue has the corresponding
pathology such as brosis, atrophy, and loss of function
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978- 981- 33- 6769- 2_12) contains
supplementary material, which is available to authorized users.
Q. Lu
General Hospital of Central Theater Command,
Wuhan, China
J. Yang · Y. Fan · C. Fang (
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
P. Wang
First Afliated Hospital, Guangzhou Medical University,
Guangzhou, China
J. Liu
Tongji Hospital, Tongji Medical College, Huazhong University of
Science and Technology, Wuhan, Hubei, China
*)
(Huang 2014). In 1957, regular hepatectomy to treat hepatolithiasis was initiated by prof. Zhiqiang Huang; later on, the
principle of “relieving the obstruction, removing lesions and
building unobstructed drainage” was described (1959). This
principle has laid the foundation for the surgical treatment of
hepatolithiasis. In 1983, The Biliary Surgery Branch of the
Chinese Medical Association established the denition,
nomenclature, and diagnostic criteria for hepatolithiasis; and
the diagnostic criteria for acute obstructive suppurative cholangitis and standards for marking stone sites were formulated. In the 1980s and 1990s, at the time when information
technology was still relatively backward, two clinical epidemiological investigations of cholelithiasis were organized.
According to 357 cases of hepatectomy and postoperative
follow-up in Southwest Hospital, the signicance of hepatolithiasis and stricture in reoperation of the biliary tract was
analyzed (Huang 2014). It was rst pointed out that the
residual hepatolithiasis and the stricture of the hepatobiliary
duct are the most common and main reasons for the failure of
surgical treatment for hepatolithiasis in China; it can cause
hyperplasia and atrophy, complicate design, and further
increase the difculty and risk of reoperation of biliary tract
surgery. Therefore, various innovative surgical methods of
portal cholangiojejunostomy have been developed. Since
then, with the continuous improvement of liver surgery technology and medical technology, hepatectomy in the treatment of hepatolithiasis has progressed. Studies on
hepatobiliary perfusion, especially microcirculation, causes,
and control of biliary bleeding, surgical treatment of endstage biliary diseases have also steadily deepened understanding. Systematic studies on the principles and methods
of surgical treatment for benign biliary diseases such as hepatolithiasis, and the application of a series of surgical methods such as hepatectomy and repair of high bile duct stricture,
have greatly improved treatment outcomes. These researches
have promoted the diagnosis and treatment of hepatolithiasis. Because of their contribution to research on hepatolithiasis, the team of Academician Huang Zhiqiang won the rst
prize of The Millennial National Science and Technology
© 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_12
239
240
Q. Lu et al.
Progress Awards. In 2007, the Department of Biliary surgery
of the Chinese Medical Association organized and published
the “Guidelines for the Diagnosis and Treatment of
Hepatolithiasis.” In 2013, the expert consensus on the laparoscopic treatment of hepatolithiasis was formulated and
published by the Committee of minimally invasive Surgeons
of the Chinese Physicians Association, which further promoted the standardized diagnosis and treatment of hepatolithiasis in China.
Despite the consensus on treatment, not every hospital
can have the well-developed infrastructure, clinical, surgical,
and technical expertise required for the effective diagnosis
and treatment of hepatolithiasis. The main reason is that
although the imaging evaluation of hepatolithiasis has developed considerably, some deciencies remain. B-ultrasound,
CT, and MRI have their advantages in the diagnosis of hepatolithiasis, but their shortcomings are obvious. B-ultrasound
can detect dilated biliary tract and calculi; however, it is challenging to show the location of bile duct stenosis due to
many factors and poor image quality. CT and MRI can comprehensively display the distribution of hepatolithiasis, dilatation of bile duct system, and pathological changes of the
hepatic parenchyma, but both of them are two-dimensional
tomographic black-and-white images. Generally, it is difcult to show the location of biliary stricture directly, nor can
we nd stones with similar density to hepatic parenchyma.
Thus, an experienced specialist is required to continuously
observe the CT images of each period to form a complete
stereoscopic image. Invasive direct biliary imaging examinations such as ERCP and PTC have the risk of inducing complications such as acute cholangitis; and they cannot observe
the pathological changes in the intrahepatic bile duct above
the narrowed bile duct segment and the extrahepatic bile
duct; nor the relationship between the vessels. The analysis
and judgment of hepatolithiasis need to be combined with
other examination methods. In particular, the above methods
displayed two-dimensional images unsuitable for objective
3D visualized imaging. It is difcult to accurately visualize
the liver tissue section with narrowed hepatobiliary duct
lesions that need to be resected invivo, and adjacent relationships with the surrounding vessels before the operation. In
the past, the understanding of the inter-relationship between
intrahepatic blood vessels and bile duct was mainly obtained
from the study of the vascular casts of autopsy specimens.
Although representing the basic situation, this method cannot fully reect the personalized characteristic of the living
body because it is derived from corpses. Surgeons’ judgment
and surgical planning are based on the subjective and comprehensive conception of the spatial position of the tissues
and organs, which presents great ambiguity and uncertainty.
For complex hepatolithiasis, especially when associated with
high bile duct stricture, or/and atrophic hyperplasia syndrome; the accurate grasp of variations of the biliary system,
portal vein, hepatic artery, and hepatic vein, as well as the
anatomic relationship between them, intrahepatic stones and
narrow biliary ducts; has decisive signicance in formulating
the surgical planning for conventional hepatectomy.
Therefore, the high uncertainty of the complicated condition of hepatolithiasis before the operation and insufcient
evaluation, limits the effective implementation of radical
therapy. As Prof. Dong etal. (2017) said, “Due to the limitations of theory and technology in the past, it was difcult to
remove the benign lesions and malignant tumors involving
the intrahepatic bile duct and liver parenchyma entirely, thus
the cure of disease could not be achieved. The effect of surgery only remains at the level of ‘relieving symptoms’.
Surgical treatment of intrahepatic bile duct lesions is a
century- long challenge in the eld of abdominal surgery.”
In the twenty-rst century, the world has entered a new
era of biological intelligence information with the rapid
development of digital technology. The integration of surgery, anatomy, imaging, computer technology, and digital
information engineering technology; which has promoted
the emergence of 3D visualization technology of hepatolithiasis. In the past 10years, the clinical practice in many hospitals has fully conrmed the unique and superior technical
guidance and support role of 3D visualization technology in
the accurate diagnosis and treatment of hepatolithiasis,
which can help surgeons to achieve the “cure effect” (Fang
etal. 2013). In January 2017, “Expert consensus on precise
diagnosis and treatment of hepatolithiasis guided by 3D
visualization technology,” jointly formulated by the Digital
Medical Branch of the Chinese Medical Association and the
Digital Medicine Clinical Surgery Committee of the Chinese
Research Hospitals, was ofcially released, indicating that it
has become a mature and advanced medical technology that
can be popularized and standardized in China. This chapter
focuses on the application of 3D visualization technology in
the accurate diagnosis and treatment of hepatolithiasis.
12.2 Preoperative Imaging
ofHepatolithiasis
The formulation of a reasonable surgical approach requires
an accurate preoperative diagnosis. The basis of preoperative
treatment planning for hepatolithiasis mainly includes imaging diagnosis, evaluation of liver physiological reserve function, and judgment of the patient’s general condition. Among
them, imaging diagnosis is the most critical, which is crucial
to the formulation of surgical plans and surgical effects.
Currently, the main imaging techniques for the diagnosis
of hepatolithiasis include B-ultrasound, CT, MRI, ERCP,
PTC, postoperative biliary drainage tube angiography, and
choledochoscopy. However, each of them has its own advantages and limitations, so it is difcult to obtain a comprehen-
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
241
sive diagnosis by a single examination. Thus, the combination
of more than one imaging examination is often required to
achieve the purpose of correct diagnosis.
12.2.1 Imaging
Ultrasound examination has great value in the diagnosis of
hepatolithiasis. Featured as noninvasive, inexpensive, and
repeatable, B-ultrasound, suitable for the screening of stones,
is the simplest initial diagnostic modality and it can show
hepatolithiasis and bile duct dilatation. Stones present as
echogenic spots with an acoustic shadow behind them.
Calcication of the intrahepatic duct system also shows
stone-like imaging, so the diagnosis of hepatolithiasis can
usually be made when marked bile duct dilatation peripheral
to the stones is seen (Sakpal etal. 2009). B-ultrasound is also
valuable in the localization diagnosis of hepatic abscess and
intrahepatic cholangiocarcinoma caused by hepatolithiasis;
however, the imaging effect on the latter is not as good as
that of CT and MRI. B-ultrasound has a high diagnostic
value for hepatolithiasis falling off to the common hepatic
duct and common bile duct. The main disadvantage is that an
overall image of the biliary tree cannot be adequately provided and B-ultrasound is not as intuitive as CT and MRI,
especially, less sensitive for hepatic parenchyma lesions
(usually hepatic brosis) caused by biliary stricture and hepatolithiasis and for biliary stricture lesions. B-ultrasound is
dependent on the prociency of the operator. Therefore,
although it can be considered as the preferred primary examination in general, other imaging examinations are still necessary to determine the condition before surgical treatment.
The sensitivity and accuracy of CT in the diagnosis of
hepatolithiasis are higher than those of B-ultrasound. CT can
show the location of hepatic hilum, dilatation of bile duct, as
well as hypertrophy and atrophy of the liver. By systematically observing all levels, we can understand the distribution
of stones in the intrahepatic bile duct and the pathological
changes of liver parenchyma. CT plain scan can show highdensity calculi, which are displayed as a corded, round, and
nodular shape in the course of the intrahepatic bile duct. Its
CT value varies according to the composition and calcium
content of the calculi. Generally speaking, high calcium content calculi have high CT value, which can clearly show the
calculi shadow, while calculi with equal density and lowdensity display poorly because of low calcium content. CT
plain scan has some limitations in the diagnosis of complications of hepatolithiasis, such as hepatic abscess and intrahepatic cholangiocarcinoma. Both showed homogeneous or
heterogeneous low-density lesions. Enhanced CT scan can
be used as a supplement to CT plain scan in the diagnosis of
hepatolithiasis and its complications. It can better reveal the
location of stones, whether the adjacent wall is thickened or
not, and whether the distal bile duct is dilated. The latter can
be manifested as a strip-like branched low-density shadow
parallel to the enhanced portal vein. Isodense calculi in the
dilated intrahepatic bile ducts show no enhancement of striplike or spot-like isodense shadow. The distal bile ducts are
slightly dilated, which is difcult to discern on CT.It is necessary to make a repeated observation of thin-layer CT
enhanced scanning and carefully measure whether the CT
value of plain scan and contrast-enhanced CT is increasing
or not, and whether the lesions are enhanced or not, so that
the diagnosis can be conrmed. Primarily because of the
characteristics of low pressure in the bile duct, it is difcult
to display the bile duct directly by the contrast medium,
which is rare or through the vascular pathway. The twodimensional CT image is always the bottleneck in the spatial
diagnosis of the stone and the stricture of the bile duct. In
general, it is difcult to display the location of biliary stricture directly, so it cannot completely cover the distribution of
stones, location of bile duct stricture, location of bile duct
stenosis, and display of bile duct tree. 3D reconstruction of
the bile duct can also be carried out by the CT image postprocessing workstation. However, the 3D reconstruction
images obtained are only the images of a particular vascular
phase. Clinicians can only be provided with 2D at lms, not
the true 3D images, with which is challenging to visualize
the stereoscopic relationship between the third stage blood
vessel and the liver and bile duct tree simultaneously. The
typical “honeycomb sign” can be observed by CT enhancement in the diagnosis of hepatic abscess complicated with
hepatolithiasis. Separation enhancement is most evident in
the arterial phase, and the degree of enhancement decreases
in the portal vein phase and delayed phase. The degree of
enhancement of the delayed period decreased; peripheral
inammation and congestion produced a noticeably patchy
enhancement in the arterial phase, and various atypical manifestations may occur during the delayed phase, which are
difcult to diagnose. Complicated cholangiocarcinoma may
present various solid, cystic, and solid lesions, often accompanied by distally dilated intrahepatic bile duct and enlarged
hilar lymph nodes, but often without specicity, which needs
to be evaluated in conjunction with other examinations.
On Plain MRI, T1- and T2-weighted images can show
hepatolithiasis, mostly strip, round, nodular low signal, or
no signal shadow. According to the different components of
the stone, T1-weighted can be a low signal, iso-signal, or
hyperintense, and the signal value of the calcium-containing
stone is low. On MRI plain scan, the shape of bile duct dilation can also be observed at the distal end of the stone,
which is shown as long strip T1 and long T2 signal. The
diagnosis of hepatolithiasis and choledocholithiasis can also
be conrmed by MRI plain scan. The most signicant
advantage of MRI combined with MRCP is that it can display the intrahepatic bile duct tree in multiple directions and
242
Q. Lu et al.
accurately judge the distribution of intrahepatic stones, the
location and extent of biliary stenosis and dilation as well as
liver parenchymal lesions. The limitation of MRI is that its
spatial resolution is not as good as that of CT. On the
T2-weighted image, the signal of bile is long, and the abnormal signal of small stones is easily “submerged.” MRI is not
as clear as CT and B-ultrasound in showing calculi. On
MRI, small stones are difcult to nd, and the stenosis of
the bile duct is not as clear and accurate as the direct cholangiography on MRI. 3D screenshots of CT and MRCP biliary system are not true 3D images, and it is difcult to
simultaneously visualize the stereoscopic anatomy of the
biliary system and other intrahepatic ducts, especially that
of the portal vein system. During contrast-enhanced MRI
scanning, although the arteries, portal vein, and hepatic
parenchyma were enhanced in each phase, the stones were
not enhanced, and the stones without enhancement were
often difcult to discern. Therefore, contrast- enhanced MR
imaging is mainly used in the diagnosis of complications of
hepatolithiasis. For example, dynamic contrast-enhanced
MR (DCE-MR) imaging can help clearly display at a distinct arterial phase not only images of multiple arterial,
venous, and delayed phases, but also the “cluster sign” of
hepatic abscess, as well as granulomatous wall and hyperemia around it accompanied by hepatolithiasis. The internal
structure of the complicated solid cholangiocarcinoma differs from the “cluster sign” in showing as an irregular mass
with delayed enhancement. There are cystic components
between solid lesions, which serve to distinguish from the
“cluster sign.”
Invasive direct biliary imaging examinations such as
ERCP and PTC are valuable in the diagnosis and treatment
of intrahepatic cholelithiasis, but they are not the rst choice
because of the possibility of inducing complications such as
acute cholangitis.
12.2.2 Other Auxiliary Examinations
12.2.2.1 Biliary Manometry
Biliary manometry can be used to determine whether bile
excretion is normal. It is not of great clinical signicance in
all scenarios involving intrahepatic cholelithiasis, however,
for stones near the porta hepatis of the left and right hepatic
ducts with bile duct stricture, the phenomenon of bile duct
dilatation, bile retention, and increased bile duct pressure
caused by inadequate bile excretion can be observed. At
present, according to the condition of the disease, electronic
biliary manometry should be selected to accurately measure
the pressure in the bile duct.
12.2.2.2 Cholescintigraphy
Technetium-99m (
99m
Tc) is commonly used in radionuclide
scanning. After intravenous injection, it is absorbed by the
mononuclear phagocyte system and excreted into the biliary
tract. 3D images can be obtained by layering and xing
points during scanning, and the relationship between the
images and adjacent structures can be displayed, which provides a good basis for diagnosis. However, the diagnosis of
intrahepatic bile duct stones is not ideal.
12.2.2.3 Selective Celiac Arteriography
Selective celiac arteriography can be used to observe the
presence of displacement, compression, interruption, and
abnormal vascular shadows in the arteries. It is useful in
the differential diagnosis of hepatobiliary and gallbladder
cancer, but the diagnosis of intrahepatic cholelithiasis is
not ideal. Moreover, arteriography requires specic equipment, complicated operation, and highly technical conditions, so it is not the rst choice for intrahepatic
cholelithiasis.
In summary, various imaging examinations have their
advantages and limitations in the diagnosis of hepatolithiasis. Therefore, for complicated cases of hepatolithiasis, it is
often necessary to evaluate them comprehensively in combination with various examinations in order to obtain more
objective diagnostic results and formulate surgical treatment
strategies.
12.3 Acquisition ofHigh-Quality
Submillimeter CT Data
The emergence of digital medical technology, represented by
3D visualization of liver and biliary tract and 3D printing
technology, provides a new method for accurate preoperative
evaluation of hepatolithiasis.
3D visualization technology is based on multi-slice CT
enhanced thin-layer scan data. For patients who are diagnosed with hepatolithiasis by B-ultrasound and intended for
establishment of a 3D visual model, the thin-section CT
scanning technique is used to collect enhanced image data of
the upper abdomen. The quality of the data in the plain, arterial, portal, and hepatic venous phases, directly affects the
accuracy of the subsequent 3D visualization model of the
hepatolithiasis.
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
243
12.3.1 Collection Equipment
64-row spiral CT-PHILIPS Brilliance 64-, 256-, or 320-slice
CT can be used. A MEDRAD double-barrel high-pressure
syringe (USA) is adopted. The image post-processing workstation is the MxView workstation that comes with the
PHILIPS Brilliance 64-slice spiral CT.Scanning parameters:
voltage 120kV, current 300 mAs, rotation time 0.5s, pitch
0.984, and layer thickness 5mm.
12.3.2 Preparation forScanning
The patient is orally administered with 500–1000 ml of
freshwater 20–30 min before the examination and another
500ml before scanning to ll the gastrointestinal tract (as a
negative contrast agent). The patient is trained to breathe to
maximize the control of artifacts caused by respiratory
movement.
12.3.3 Plain Scan
High-resolution volumetric scanning in the submillimeter
state. The patient is placed in a supine position with a routine
scan in the direction of head to foot. The scanning range is
from the top of diaphragm to the lower edge of the liver, and
the scanning condition is 120kV, 300 mAs; 0.625×64 rows
of detectors are combined, with 5mm of thickness, 5mm of
interval, 0.984 of pitch, 0.5s of bulb rotation, 40–50cm of
scanning eld of vision, 512×512 of matrix. A routine upper
abdominal plain scan is performed.
12.3.4 Dynamic Enhanced CT Scan
After the plain scan, the contrast agent is injected into the
cubital vein (with cannula needle), the injection rate is 5ml/s
with a double tube CT high-pressure injector. The contrast
agents are high concentration of Nonionic iodipin 370 (370
mgI/ml) or iopromide 370 (370 mgI/ml). At a dose of 1.5ml/
kg, the tube is washed with 50 ml of normal saline after
injection of the contrast agent. The scanning conditions are
the same as that of the plain scan. The scanning delay is
20~25s in the arterial phase and 50~55s in the intravenous
phase. After scanning, the enhanced raw data is applied to
perform the thin layer reconstruction of 0.67 mm with an
interval of 0.33mm, and the image data is transferred to the
MxView workstation.
12.3.5 Acquisition ofThin-Slice CT Data
On the MxView diagnostic workstation, all the data is
recorded by CD-ROM, including the data of liver and bile
duct stones during plain scan phase, arterial phase, portal
venous phase, and hepatic venous phase, all in the format of
DICOM 3.0.
12.4 Reconstruction of3D Visualized
Model forHepatolithiasis
Thin-slice CT data are processed by image workstation and
imported into MI-3DVS for program segmentation and
reconstruction. By adjusting the transparency of the liver, the
structure of the liver, hepatic artery, hepatic vein, and the primary, secondary and tertiary branches of the portal vein are
displayed, so do the stricture of the biliary tract and the
dilated bile duct of the rst to fourth grade; the size, shape,
and distribution of the stones are also displayed. Through the
rotational observation of the model, the spatial position relationship of each pipeline structure is clearly understood.
12.4.1 Image Registration
Adjust the scanning sequence of each phase. The original
CT images are read with a DICOM viewer. These images
are registered, converted into BMP format, and saved in a
new folder (Fig. 12.1). In the MI-3DVS, the adaptive
region growth algorithm is used to segment the liver
sequence, and the 3D dynamic region growth method is
used to perform automatic segmentation of the liver pipeline system. It has the advantages of high speed and good
accuracy and overcomes the shortcomings of manual segmentation. The segmented data can be reconstructed
quickly by using the moving cube algorithm of surface
rendering, which is benecial to the research of visual
simulation surgery.
244
Q. Lu et al.
a
b
Fig. 12.1 Image registration. (a) CT images are read with a DICOM
viewer; (b) images are converted and saved as BMP format les in the
DICOM viewer; (c) BMP images of left intrahepatic bile duct stones
with atrophy; (d) BMP images of left intrahepatic bile duct dilatation
and calculi
concretion
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
245
c
Fig. 12.1 (continued)
in left liver
12.4.2 Image Automatic Segmentation and3D
Reconstruction
The patient’s BMP data were imported into the MI-3DVS
system. Then the 3D model was automatically segmented
and reconstructed with the same method. Finally, the 3D
model was output in STL format (Fig. 12.2a–h); the STL
format of the model containing hepatolithiasis and liver systems were imported into the FreeForm Modeling System to
be processed and smoothed. The senses of layering and noise
were also removed. A 3D model of each system (Fig.12.3a–
h) and a hepatobiliary model was created (Fig.12.4).
The abdominal aorta and its branches, hepatic artery, and
left hepatic artery, right hepatic artery, and its subordinate
branches are all clearly displayed (Fig.12.3a).
• Portal vein phase: The main portal vein and grade 5
branches are well displayed. The splenic vein and supe-
rior mesenteric vein can be seen (Fig.12.3b).
• Hepatic vein phase: In the absence of hepatic atrophy and
cholangiocarcinoma, the main trunk of the hepatic vein
showed well. Normally, the branches of the hepatic vein
can be displayed. In this case, the left hepatic vein cannot
be clearly displayed due to the atrophy and deformation
of the left lateral lobe of the liver, resulting in the observed
variation of the left hepatic vein (Fig.12.3c).
• Bile duct dilatation of the left extrahepatic lobe can be
seen in the reconstructed biliary system (Fig.12.3d).
• Left intrahepatic cholelithiasis (Fig. 12.3e) can be seen
when the transparency of the bile duct is set at 25.
d
• The contour of the liver was clear, and the left lateral lobe
was atrophied and deformed (Fig.12.3f).
The above method was the procedure for 3D reconstruc-
tion in the past. Now, an optimized 3D visualization system
for abdominal medical images is used. In the process of 3D
reconstruction, the software can directly read the original
DICOM data of the patient (no format conversion is required)
and then carry out automatic registration and system reconstruction, which has dramatically improved the working
efciency.
12.5 3D Visualized Vascular Classication
The liver, biliary tract, stones, and intrahepatic blood vessels were observed and analyzed based on the obtained 3D
visualized images of the individualized liver, vessels,
stones, and peritoneal vessels, and surrounding organs. For
patients without liver atrophy, hypertrophy or biliary cirrhosis, 3D visualization of hepatic artery classication,
and hepatic vein classication (see Sect. 16.3); 3D visual
portal vein classication can be divided into the following
5 types.
12.5.1 Classication ofPortal Vein Branches
Normal Type The main portal vein was divided into left
and right branches at the porta hepatis (Fig.12.5).
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Q. Lu et al.
a
b
Fig. 12.2 Automatic image segmentation. (a) BMP data are imported
into the MI-3DVS for segmentation; (b) 3D reconstruction is performed
in the MI-3DVS; (c) segmentation of the liver; (d) segmentation of left
intrahepatic bile duct dilation; (e) segmentation of left intrahepatic bile
duct stones; (f) segmentation of the arterial system; (g) segmentation of
the portal vein system; (h) segmentation of hepatic and inferior vena
cava systems