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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_585_Библиотеки_им_академика_М_И_Перельмана.pdf
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12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
257
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2
3
4
5
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Fig. 12.19 Distribution of portal vein in four hepatic vein regions
Fig. 12.21 Anatomical
relationships among the
biliary tract, portal vein, and
hepatic vein
7
1
8
4
Fig. 12.20 Spatial anatomy after registration of portal vein and biliary
tract
The hepatic ve
5
6
7
The portal system
The dilated biliary ducts
and calculus
258
ein
y ducts
Q. Lu et al.
the atrophy of the liver; Type II c: diffuse type, accompanied
by extensive brosis of hepatic parenchyma resulting in secondary biliary cirrhosis and portal hypertension, usually with
severe stricture of the bile duct below the right and left
hepatic duct or conuence. At the same time, the patients
with extrahepatic cholelithiasis are divided into three subtypes according to the functional status of Oddi sphincter:
Ea: Oddi sphincter was normal and Eb: Oddi sphincter relaxation. Ec: Oddi sphincter stenosis.
The criteria in this guideline will help clinicians by providing a classication of complicated hepatolithiasis, to standardize the diagnosis and treatment according to the
corresponding treatment plan of each type. The results of
prospective and retrospective clinical studies can be summa-
The hepatic v
The portal vein
Fig. 12.22 Hepatic and portal veins
rized and analyzed according to unied criteria so that the
conclusions are more realistic and objective and have important guiding signicance for clinical research and treatment.
In 2017, a digital clinical classication of hepatolithiasis
was established through the combination of the 3D visual
imaging features of hepatolithiasis and the “Expert consensus
on precise diagnosis and treatment of hepatolithiasis guided
by three-dimensional visualization technology” formulated by
the Digital Medicine branch of the Chinese Medical
Association and the Digital Medical Committee of Clinical
Surgery of the Chinese Research Hospital Society. This expert
consensus was based on the “Guidelines” (2007 edition).
The digital classication of hepatolithiasis under the
guidance of 3D visualization is set based on the comprehensive evaluation of location (L) of stones in different liver segments, the specic location of biliary stenosis (S) or
distention (D), and whether it is associated with hepatic atrophy (A) or cirrhosis (C) because the stereoscopic morphology and relationship of intrahepatic “bile duct tree” and
“vascular tree,” the size and distribution of stones in various
hepatobiliary ducts, the degree and extent of biliary stenosis,
the variation of blood vessels and the atrophy of the liver can
be displayed in the stereoscopic model constructed by 3D
visualization technique. The specic classication is shown
in Figs.12.37, 12.38, 12.39, 12.40, 12.41, 12.42, 12.43, and
12.44. For example, Fig.12.37: hepatolithiasis L
S
left and right hepatic duct
, D
II, III, VI, and VII
, and C, indicating stones in
II, III, VI, VII
,
the II, III, VI, and VII segments of the liver, the left and right
hepatic bile duct stenosis, II, III, VI, VII bile duct dilatation,
and liver cirrhosis.
Fig. 12.23 Biliary tract and
portal vein
The dilated biliar
and calculus
The portal vein
y
in
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
259
Fig. 12.24 Stereoscopic
anatomy of the biliary tract,
hepatic vein, and portal vein
Fig. 12.25 Stereoscopic
anatomy of the portal vein
and hepatic vein
The hepatic vein
The dilated biliar
ducts
The portal vein
The hepatic ve
The digital classication is concise, convenient, practical, accurate, and fast; this classication can be generated
immediately after the preoperative 3D evaluation. It further
standardizes the establishment of a 3D visual model of hepatolithiasis, which is helpful for clinicians to quickly establish a clear and accurate understanding of the patient’s
basic condition. Therefore, the clinical classication and
management of cholelithiasis based on the “Guidelines”
The portal vein
(2007 edition) can be correctly understood and implemented. This method provides a new strategy for the accurate diagnosis and treatment of intrahepatic cholelithiasis.
For example, Fig.12.44 can clearly show that right hepatolithiasis in segments V, VI, VII, and VII, accompanied by
right hepatic stenosis, and atrophy of segments VI and VII,
which can guide clinicians to perform precise anatomical
right hepatectomy.
260
s
s
Fig. 12.26 Stereoscopic
anatomy of the portal vein,
bile duct, and calculus
Fig. 12.27 Stereoscopic
anatomy of the bile duct,
stone, and vascular system
Q. Lu et al.
The dilated biliary duct
and calculus
The portal
vein
The hepatic vein
The dilated biliary duct
and calculus
The portal vein
ein
y ducts and
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.28 Stereoscopic
anatomy of the portal vein
and hepatic vein
261
The hepatic
vein
The portal v
Fig. 12.29 Stereoscopic
anatomy of the portal vein
and biliary tract
The dilated biliar
calculus
The portal vein
262
y ducts and
Fig. 12.30 Stereoscopic
anatomy of the biliary tract,
portal vein, and hepatic vein
Q. Lu et al.
The hepatic vein
The dilated biliar
calculus
The portal vein
Fig. 12.31 Stones in segments II, III, IV, VII, and VII
Fig. 12.32 Stones in segments II, III, and IV
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
The stone
Fig. 12.33 Stones in segments VI and VII
263
Fig. 12.35 Stones are seen when segments V and VII are removed
Fig. 12.34 Stones are seen when segment II is removed
Fig. 12.36 Stones are seen when segments VI and VII are transparent
264
Fig. 12.37 Hepatolithiasis
L
D
II, III, VI, VII
II, III, VI, and VII
, S
left and right hepatic duct
, and C
Fig. 12.38 Hepatolithiasis;
observe the relationship
between the portal vein and
bile duct (front view); S
right hepatic duct
and D
left and
II, III, VI, and VII
Q. Lu et al.
,
Fig. 12.39 Hepatolithiasis;
observe the relationship
between the hepatic artery
and bile duct (superior view);
S
right hepatic duct
and D
II, III, VI, and VII
ducts and calculus
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.40 Hepatolithiasis
L
II, III, VI, and VII, SII, III, right, VI, and VII,
D
II, III, IV, VI, and VII
, C
265
The liver
The dilated biliary
12.8.1 Secondary Development ofVirtual
Surgical Instruments andSimulated
Surgery
Fig. 12.41 Hepatolithiasis L
II–VII
, S0, D
II–VII
, C
0
12.8 Preoperative Planning andSurgical
Simulation
The use of a 3D visual virtual system to simulate the operation of hepatolithiasis before an operation helps nd the best
operative approach and treatment method. The virtual simulation surgery system has advantages such as interoperability
and repeatability. It can simulate and predict complex and
dangerous situations that may occur in the actual operation.
Through the simulation of different surgical schemes, the
advantages and disadvantages of these schemes can be compared. In this way, a reasonable and individualized operation
program can be selected.
The STL format of the 3D model of hepatolithiasis and the
mold of the customized surgical instrument, were imported
into the FreeForm Modeling System. By using the force
feedback device of the system (PHANTOM), the model
could be magnied, reduced, and rotated. After the determination of the route of liver resection and activation of the
virtual liver, the liver could be cut with a virtual scalpel. The
hepatic artery branch and portal vein branch of the liver section could be sutured and ligated, and the hepatic vein branch
and bile duct branch cut off to complete the visual virtual
hepatectomy.
12.8.2 Examples ofSimulated Liver Resection
forHepatolithiasis
12.8.2.1 Simulated Liver Resection forLeft-
Sided Hepatolithiasis
The 3D model of liver and gallbladder with left hepatolithiasis was reconstructed and imported into the FreeForm
Modeling System. By controlling the transparency of the
liver and the biliary tract, all the structures of the liver and its
internal organs can be observed and displayed, including the
bile duct, hepatic artery, portal vein, hepatic vein, the abdominal aorta, and inferior vena cava. They were consistent with
the true structure, especially the bile duct dilatation and multiple stones with atrophy of the left extrahepatic lobe, showing clear structure, accurate location, and delity to the
266
ab
Q. Lu et al.
1
2
7
Fig. 12.42 Hepatolithiasis L
II, III, IV, and VI
, S
left hepatic duct
, D
II, III, IV, VI, and VII, C0
3
4
5
6
. (a) Anterior view; (b) overall view
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9
10
11
Fig. 12.43 Hepatolithiasis L
C
0
II, III, IV
, S
left and right hepatic duct
, D
II, III, IV, VI, and VII,
Fig. 12.44 Hepatolithiasis L
V, VI, VII, and VII
, S
right hepatic duct, DV, VI, VII, and VII
, C
0