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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_585_Библиотеки_им_академика_М_И_Перельмана.pdf
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
c
247
d
Fig. 12.2 (continued)
248
Q. Lu et al.
e
f
Fig. 12.2 (continued)
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
g
249
h
Fig. 12.2 (continued)
250
in
Q. Lu et al.
a
The proper
hepatic artery
The gastroduodenal
artery
The right hepatic vein
c
e
The middle hepatic vein
The left hepatic vein
The right hepatic duct
The calculus
The left hepatic duct
b
The main
portal ve
The right hepatic duct
d
f
The left hepatic
The common hepatic
duct
The gallbladder
Left
hepatatrophy
The common hepatic
duct
The gallbladder
g
Fig. 12.3 3D models of each system. (a) The reconstructed arterial
system; (b) the reconstructed portal vein system; (c) the reconstructed
hepatic vein and inferior vena cava; (d) the reconstructed biliary tract;
(e) the calculus of the bile duct is observed in the left outer lobe when
The hepatic vein
The hepatic artery
The bile duct
The portal vein
Type I Variation The portal vein was divided into the left
branch, right anterior branch, and right posterior branch at
the porta hepatis (Fig.12.6).
h
the transparency of the biliary system is 0.5; (f) Atrophy of left outer
lobe is observed in the reconstructed liver; (g) the 3D model when the
liver transparency is 0; (h) the 3D model of the hepatic internal structure is displayed when the liver transparency is 0.5
Type II Variation Portal vein rst issued the right posterior
branch, then moving upward to be divided into the right anterior branch and the left branch (Fig.12.7).
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.4 The 3D model when
the liver transparency is 1
251
RA
RP
Fig. 12.5 Normal type
LT
RA LT
RP
Fig. 12.6 Type I
252
RA LT
RP
Fig. 12.7 Type II
LT
Q. Lu et al.
Fig. 12.9 Other variations
12.6 Individualized Liver Segmentation
andVolume Calculation for3D
Visualization ofHepatolithiasis
RA
RP
Fig. 12.8 Type III
Type III Variation The right branch of the portal vein was
horizontally divided into an anterior branch and posterior
branch (Fig.12.8).
Other Variations
The absence of the left branch of the por-
tal vein; special variations: left branch of portal vein came
from the right anterior branch (Fig.12.9).
In patients with liver atrophy, hypertrophy, or biliary cirrhosis, 3D visualization and evaluation of liver vascular are particularly crucial for selecting surgical methods as well as
reducing the incidence of surgical complications and risk
because of its pathological changes.
In 1954, Couinaud (1954) divided the liver segment according to the distribution of the liver Glisson system and the
course of the hepatic vein and proposed a relatively complete
eight-segment method. He divided the liver into left and right
halves, four lobes, and eight functional segments. Each liver
segment can be considered as a functional anatomical unit of
the liver. The Couinaud segmentation classication has
become the anatomical basis of liver imaging and liver surgery and has been widely used in clinical practice. However,
it also has apparent defects because it is the research result of
in vitro liver casting, and its orientation term is for the
desktop, so it does not accord with the actual situation of
in vivo liver. Moreover, with the development of imaging
techniques, more and more studies show that only some of
the liver segments accord with Couinaud classication due
to the variation of hepatic vein and portal vein branches.
In addition to physiological changes, in patients with
complex hepatolithiasis, the portal vein is compressed and
deformed due to dilatation or inammatory changes of the
biliary system, resulting inlocal liver tissue nutrition deciency and brotic atrophy. In contrast, the healthy liver
exhibits compensatory proliferation, leading to atrophy and
hypertrophy of the liver, and even hepatic portal transposition. The hepatic segment with hepatolithiasis was different
from that of a healthy liver. The hepatic vein and portal vein
system (Figs. 12.10, 12.11, 12.12, 12.13, 12.14, 12.15,
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
253
Fig. 12.12 Staining of Segments V, VI, VII, and VII
Fig. 12.10 Individualized segmentation
Fig. 12.11 Staining of Segments II, III, and IV
Fig. 12.13 Overall view of segmentations
254
Fig. 12.14 Segments II, III, IV, V, and VII
Q. Lu et al.
Fig. 12.15 Hypertrophy of segments V and VII, and contraction of
segments VI and VII
12.16, and 12.17) are deformed, as the branches of the por-
tal vein in adjacent liver tissue enlarge to compensate for the
deformations of the hepatic and portal veins caused by
stones. As a result, portal vein and hepatic veins deviate
from their normal paths, and are mostly deviated from the
traditional Couinaud segment. Liver atrophy and hypertrophy or liver transposition were observed. In this case, surgi-
Fig. 12.16 Overall view of s hepatic segments
Fig. 12.17 Stones at segments III, IV, V, VI, VII, and VII
cal resection, according to the traditional Couinaud
segmentation, will inevitably lead to uncertainty of the cutting edge, thus affecting the therapeutic effect. Therefore,
the preoperative 3D visualization of individualized liver
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
255
segmentation in patients with hepatolithiasis has important
guiding signicance for the diagnosis and formulation of
surgical methods.
12.6.1 Semiautomatic Liver Segmentation
The reconstructed STL format was imported into the
FreeForm Modeling System. After smoothing and denoising,
the liver was translucent, and the individualized liver segmentation was performed according to the blood ow topological relationship (Fig.12.18). The liver segments of each
functional area were determined by the independent portal
vein blood supply and hepatic venous reux, and each segment of the liver was divided into different colors for
comparison.
12.6.2 Hepatic Segment forHepatolithiasis
Through 3D rotational observation of portal vein and hepatic
vein, the liver was divided into three, four, or even ve sections according to the branches of the hepatic vein. Then the
portal vein, biliary tract, and hepatic vein were registered to
observe the relationship between the portal vein and bile
duct branches in the hepatic veins (Figs.12.19, 12.20, 12.21,
12.22, 12.23, 12.24, 12.25, 12.26, 12.27, 12.28, 12.29, and
12.30). The segments were marked with different colors
(Figs.12.10, 12.11, 12.12, 12.13, 12.14, 12.15, 12.16, and
12.17) to complete the individualized liver segmentation.
The color of each segment was hidden or transparent to some
degree. The stones and bile ducts were displayed separately
or simultaneously. The distribution of stones and bile duct
lesions in each hepatic segment can be clearly observed by
rotating observation at different angles (Figs.12.31, 12.32,
12.33, 12.34, 12.35, and 12.36). The precise localization
diagnosis of stones and bile duct lesions can be made.
The main factors to be considered comprehensively during surgery include the following aspects: the blood supply
system (hepatic artery and portal vein) of the site to be
resected, the reux system (hepatic vein) of the remaining
liver, and the remaining liver volume. The 3D reconstruction
image can observe the blood supply artery, portal vein, and
reuxing hepatic vein of the site to be resected and measure
the distance between it and the secondary branch and tertiary
branch of the hepatic artery and portal vein. Therefore,
whether the surgical procedure is regular hepatic segment
hepatectomy or irregular hepatectomy, and whether residual
hepatic vein reux is affected, can be determined. 3D reconstruction images showed the branches of the portal vein and
hepatic artery at more than three levels and clearly showed
the 3D morphology of three sets of the vascular system in the
liver, and their spatial anatomical relationship with the site to
be excised. Individualized liver segmentation and volume
measurement are ensured. Based on the principle of
Couinaud segmentation, the 3D visualized liver segmentation function was adopted, which accords with the anatomical characteristics of the individualized portal vein. It can
accurately locate the liver segment where the stone is located,
as well as calculate the volume of the whole liver, the liver
segment where the stone is located, and the residual liver
segment; thus providing an accurate basis for the evaluation
of liver volume.
12.7 Clinical Diagnosis ofHepatolithiasis
with3D Visualization
Appropriate disease classication can not only reect the
anatomical features and pathophysiological changes of diseases but also guide the treatment. The main pathological
features of hepatolithiasis are biliary obstruction, infection,
destruction, and proliferation of hepatic parenchyma. Due to
the dilatation of the intrahepatic bile duct, thickening of the
wall, proliferation of brous tissue, and massive inltration
of inammatory cells, the portal vein branches are compressed, distorted, narrowed, blood ow is decreased and the
corresponding hepatic parenchyma atrophied. The compensatory hypertrophy of normal liver tissue forms liver atrophyhypertrophy syndrome. Moreover, cholestasis can also cause
complications such as biliary tract infection, biliary liver
abscess, acute suppurative cholangitis, subphrenic abscess,
biliary stula, and biliary bleeding. The above pathological
changes and the location of the stones and diseased bile ducts
have become the main considerations for the classication of
hepatolithiasis.
In the past, hepatolithiasis classication was based on
stone component classication, Nakayama classication,
and Tsunoda classication. In 2007, the Biliary Surgery
branch of the Chinese Medical Association formulated and
issued “Guidelines for Diagnosis and Treatment of
Hepatolithiasis” (2007), In the guideline, based on (a) the
clinical manifestation of the patient as well as conditions
such as the distribution of stones in the liver, (b) the degree
of pathological changes of the corresponding hepatic duct
and liver, and (c) the complication of extrahepatic bile duct
stones, hepatolithiasis was divided into two main types: type
I and type II.Type I is called regional type, with stones localized in one or several segments along the intrahepatic bile
duct tree, often accompanied by stenosis of the hepatic duct
and atrophy of the affected segments; Type II was divided
into three subtypes according to the hepatic parenchyma
lesions: type II a: diffuse type, without obvious brosis and
atrophy of the hepatic parenchyma. Type II b: diffuse type
with regional brosis and atrophy of the hepatic parenchyma,
usually accompanied by stenosis of the main hepatic duct in
256
Q. Lu et al.
ab
cd
e
Fig. 12.18 Individualized liver segmentation. (a) Individualized
hepatic segments (segment 5); (b) individualized hepatic segments
(segment 7); the arrow points to segment 1; (c) individualized hepatic
segments (segment 8); (d) individualized hepatic segments (segment 9);
(e) individualized hepatic segments (segment 10)