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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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- •Foreword I
- •Foreword II
- •Foreword III
- •Foreword IV
- •Contributors
- •Manuscripts Translation and Preparation
- •1.1 Introduction
- •Preface
- •Acknowledgments
- •Contents
- •Editors and Contributors
- •Deputy Editors
- •1.2.2.2 Gallbladder
- •1.2.2.3 Cystic Duct
- •1.2.2.4 Common Bile Duct
- •Supraduodenal Portion
- •Retroduodenal Portion
- •Pancreatic Portion
- •Intraduodenal Portion
- •1.3.2 Data Acquisition
- •1.3.2.2 Bile Duct Perfusion
- •1.3.2.3 Hepatic Artery Perfusion
- •1.3.2.4 Specimen Perfusion Fixation
- •1.4.1 Liver Dissection after Biliary Tract Perfusion
- •1.4.3.1 Image Registration After Bile Duct Perfusion
- •References
- •2.1 Introduction
- •2.2.1 Basic Principles
- •2.2.2.1 Methods
- •Preparation
- •Scanning Modalities
- •Contrast-Enhanced Scanning
- •Contrast-Enhanced Examination
- •Shaded Surface Display
- •Maximum Intensity Projection
- •Volume Rendering
- •2.3.1.1 MRI Devices
- •The Magnet
- •The Gradient System
- •The Radiofrequency System
- •Radiofrequency Coils
- •The Computer System
- •Other Auxiliary Equipment
- •2.3.2.1 MRI Preparations
- •Patient Preparation
- •2.3.2.2 Regular Scan Sequences
- •Single-Shot Turbo Spin-Echo Coronal Sequences
- •2D or 3D T2W1
- •Transaxial Single-Shot Turbo Spin-Echo Fat Suppression Sequences
- •Dynamic Enhancement Sequence
- •3D Volumetric Acquisitions
- •Advantages
- •Disadvantages
- •2D Continuous Thin-Slice Scanning
- •Advantages
- •Disadvantages
- •2D Thick-Slice Projection Imaging
- •Advantages
- •Disadvantages
- •References
- •3.1 Introduction
- •3.2 Congenital Biliary Diseases
- •3.2.1 Congenital Extrahepatic Biliary Atresia
- •3.2.1.1 CT Features
- •3.2.1.2 MRI Features
- •3.2.2 Biliary Dilatation
- •Type I
- •Type II
- •Type III
- •Type IV
- •Type V
- •3.2.2.2 Radiographic Features
- •CT Features
- •MRI Features
- •3.2.3 Bile Duct Hamartomas
- •3.2.3.1 CT Features
- •3.2.3.2 MRI Features
- •3.3 Common Gallbladder Diseases
- •3.3.1 Acute Cholecystitis
- •3.3.1.1 Radiographic Features
- •CT Features
- •MRI Features
- •Gangrenous Cholecystitis
- •Emphysematous Cholecystitis
- •Pediatric Cholecystitis
- •Pregnancy Cholecystitis
- •Gallbladder Empyema
- •Gallbladder Perforation
- •Hemorrhagic Cholecystitis
- •3.3.5 Other Gallbladder Tumors
- •3.3.5.3 Primary Gallbladder Lymphoma
- •3.3.5.4 Gallbladder Fibrosarcoma
- •3.3.6 Xanthogranulomatous Cholecystitis
- •3.3.6.1 CT Features
- •3.3.6.2 MRI Features
- •3.3.7 Gallbladder Adenomyomatosis
- •3.3.2 Chronic Cholecystitis
- •3.3.2.1 CT Features
- •3.3.2.2 MRI Features
- •3.3.3 Gallstones
- •3.3.3.1 CT Features
- •3.3.3.2 MRI Features
- •3.3.4 Gallbladder Cancer
- •3.3.4.1 CT Features
- •3.3.4.2 MRI Features
- •3.3.4.3 MRCP Features
- •3.3.7.1 CT Features
- •3.3.7.2 MRI Features
- •3.3.8.1 CT Features
- •3.3.9 Gallbladder Torsion
- •3.3.9.1 Type I
- •3.3.9.2 Type II
- •3.3.10.2 Gallbladder Sludge
- •3.3.11 Mirizzi’s Syndrome
- •3.3.11.1 CT Features
- •3.3.11.2 MRI Features
- •3.3.12 Post-Cholecystectomy Syndrome
- •3.4.1 Bile Duct Stones
- •CT Findings
- •MRI Findings
- •CT Findings
- •MRI Findings
- •3.4.2 Suppurative Cholangitis/Acute Cholangitis
- •3.4.3 Primary Sclerosing Cholangitis
- •3.4.3.1 CT Findings
- •3.4.3.2 MRI Findings
- •3.4.4 Secondary Sclerotic Cholangitis
- •3.4.5 Recurrent Pyogenic Cholangitis
- •3.4.5.1 CT Findings
- •3.4.6 Extrahepatic Cholangiocarcinoma
- •3.4.6.1 CT Findings
- •MRI Findings
- •MRCP Features
- •3.4.7 Intrahepatic Cholangiocarcinoma
- •3.4.7.3 Special Manifestations
- •3.4.8 Periampullary Carcinoma
- •3.4.8.1 Radiographic Findings
- •3.4.8.2 CT Findings
- •3.4.8.3 MRI Findings
- •3.4.9 Combined Hepatocellular-Cholangiocarcinoma
- •3.4.9.1 Imaging Findings
- •3.4.9.2 MRI Findings
- •3.5.1.1 Intrahepatic Biliary Dilatation
- •CT Findings
- •MRI Findings
- •3.5.1.2 Extrahepatic Bile Duct Dilatation
- •3.5.2.1 Hilar Obstruction
- •3.5.2.3 Pancreatic Obstruction
- •References
- •4.1 Introduction
- •4.1.2.1 CT Acquisition Protocols
- •4.1.2.2 Data Preprocessing
- •4.1.2.3 Medical Image Segmentation
- •4.1.2.4 3D Visualization
- •4.2.1 Image Registration
- •4.2.1.1 Template Matching Algorithm
- •4.2.1.2 Registration Steps
- •Step 1
- •Step 2
- •Step 3
- •4.2.2 Image Segmentation
- •Pixel Based Methods
- •Region Based Methods
- •Edge Based Methods
- •Model Based Methods
- •4.2.2.3 Serialized Segmentation Model
- •4.2.2.4 Adaptive Region Growing Algorithm
- •4.2.3 3D Reconstruction
- •References
- •5.1 Introduction
- •Fused Deposition Modeling
- •Stereolithography
- •Selected Laser Sintering
- •Direct Metal Laser Sintering
- •Laminated Object Manufacturing
- •Electron Beam Melting
- •Three-Dimensional Printing
- •High-Performance 3D Reconstruction Software
- •5.1.2.2 Medical Model Manufacturing
- •5.1.2.3 Tissue/Organ Regeneration
- •5.2.2 Digital Preparation
- •5.3.1.1 In Complex Liver Resection
- •5.3.1.2 In Liver Transplantation
- •5.3.2.1 In Cholangiocarcinoma Surgery
- •5.3.4 Prospects
- •References
- •6.1 Introduction
- •6.1.1 Virtual Anatomy
- •6.1.2 Surgical Simulation
- •Improved Doctor–Patient Relationship
- •Reduced Surgical Costs
- •Remote Intervention
- •6.2 Virtual Surgical Instruments
- •6.2.1 Geometric Modeling
- •6.2.2 Motion Modeling
- •6.2.3 Physical Modeling
- •6.3 Surgical Simulation
- •6.3.1 The Hardware System
- •6.3.2 Software System
- •6.3.2.1 FreeForm Modeling System
- •6.3.2.2 Open Graphics Library
- •6.3.2.3 Tactile Development Kit
- •6.4.4 Discussion
- •References
- •7.1 Introduction
- •References
- •8.1 Introduction
- •8.2 Duodenoscopy
- •8.3 Choledochoscopy
- •8.3.1 Preoperative Application
- •8.3.2 Intraoperative Application
- •8.3.3 Postoperative Application
- •8.4 Capsule Endoscopy
- •8.5 Laparoscope
- •8.6 Endoscopic Ultrasound
- •8.7 3D Visualization-Assisted Endoscopic Technology
- •References
- •9.1 Introduction
- •9.3.1.1 Arterial Phase
- •9.3.1.2 Portal Venous Phase
- •References
- •10.1 Introduction
- •10.2.1.2 Image Segmentation
- •10.2.1.3 3D Reconstruction
- •10.2.1.4 Surgical Simulation
- •Surgical Procedure
- •References
- •11.1 Introduction
- •11.2.2 Image Registration
- •References
- •12.1 Introduction
- •12.2.1 Imaging
- •12.2.2 Other Auxiliary Examinations
- •12.2.2.1 Biliary Manometry
- •12.2.2.2 Cholescintigraphy
- •12.2.2.3 Selective Celiac Arteriography
- •12.3.1 Collection Equipment
- •12.3.3 Plain Scan
- •12.3.4 Dynamic Enhanced CT Scan
- •12.4.1 Image Registration
- •12.6.1 Semiautomatic Liver Segmentation
- •Surgical Procedures
- •Surgical Procedures
- •12.10.2 Anatomical or Regular Hepatectomy Guided by 3D Visualization
- •12.10.2.1 Indications
- •12.10.2.2 Contraindications
- •12.10.2.4 Surgical Procedures
- •For Anatomical Right Hemihepatectomy
- •For Anatomical Left Hemihepatectomy
- •12.10.3.1 Contraindication
- •12.10.3.3 Surgical Procedures
- •Case 1
- •Case 2
- •12.10.4.1 Indications
- •12.10.4.2 Contraindication
- •12.10.4.4 Surgical Procedures
- •12.10.4.5 Attention
- •12.10.5.1 Indications
- •12.10.5.2 Contraindications
- •12.10.5.3 Surgical Procedures
- •12.10.5.4 Attention
- •12.10.6.1 Indications
- •12.10.6.2 Contraindications
- •12.10.6.3 Preoperative Imaging Evaluation
- •12.10.6.4 Surgical Procedures
- •12.10.6.5 Attention
- •12.10.7.1 Indications
- •12.10.7.2 Contraindications
- •12.10.7.3 Surgical procedures
- •12.10.7.4 Attention
- •12.10.8.1 Preoperative Evaluation
- •12.10.8.2 Preoperative Preparation
- •12.10.8.3 Contraindications
- •12.10.8.4 Operation Methods
- •12.10.8.5 Attention
- •12.10.9.1 Biliary Injury
- •Causes
- •Preventive Measures
- •12.10.9.2 Biliary Bleeding
- •12.10.9.3 Gastrointestinal Water Retention
- •Reasons
- •12.10.9.4 Biliary Leakage
- •12.11.1.1 Reasons
- •Main Reasons
- •Iatrogenic Biliary Tract Injury
- •Other Reasons
- •12.11.1.3 Surgical Procedures
- •Roux-en-Y Choledochojejunostomy
- •Hepatectomy
- •Intrahepatic Lithotripsy Through Sinus Tract or PTCS
- •Severe Symptomatic Patients
- •References
- •13.1 Introduction
- •13.3.1 Ultrasonography
- •13.3.2 Multi-Slice CT
- •13.3.5 Intraoperative Cholangiography
- •13.3.6 Radionuclide Hepatobiliary Scan
- •13.3.7 Digital Medicine Technology
- •Periampullary Tumor
- •Biliary Atresia
- •Acute Pancreatitis
- •Acute Cholecystitis
- •Hepatic Cyst
- •Hepatic Echinococcosis
- •Retroperitoneal Cystic Masses
- •13.4.2.1 Biliary Drainage
- •13.4.2.3 Liver Resection
- •13.4.2.4 Pancreaticoduodenectomy
- •13.4.2.5 Liver Transplantation
- •13.4.2.6 Laparoscopic Surgery
- •13.4.2.7 Reoperation
- •References
- •14.1 Introduction
- •14.1.1.1 Etiology
- •Anatomical Factors
- •Pathological Factors
- •Surgeon Factors
- •14.1.2.2 End-to-End Cholangiostomy
- •14.1.2.3 Choledochoduodenostomy
- •14.1.2.4 Roux-en-Y Cholangiojejunostomy
- •14.1.2.7 Liver Transplantation
- •14.2.2.1 Patient Information
- •14.2.2.2 Diagnosis
- •14.2.2.3 Complaint
- •14.2.2.4 History
- •14.2.2.5 Signs
- •14.2.2.6 Previous History
- •14.2.2.7 Laboratory Examination
- •Blood Routine
- •Coagulation Function
- •Liver Function
- •Renal Function
- •Tumor Markers
- •14.2.2.8 General Condition Assessment
- •Nutritional Status Evaluation
- •Liver Function Evaluation
- •Important Organ Function Evaluation
- •14.2.2.9 Imaging Evaluation
- •Evaluation by 3D Visualization
- •14.2.2.10 Surgical Planning
- •14.2.2.11 Surgical Procedures
- •Step 1
- •Step 2
- •Step 3
- •14.2.3.1 Patient Information
- •14.2.3.2 Diagnosis
- •14.2.3.3 Complaint
- •14.2.3.4 History
- •14.2.3.5 Signs
- •14.2.3.6 Previous History
- •14.2.3.7 Laboratory Examination
- •Blood Routine
- •Coagulation Function
- •Liver Function
- •Renal Function
- •Tumor Markers
- •14.2.3.8 General Condition Assessment
- •Nutritional Status Evaluation
- •Liver Function Evaluation
- •Important Organ Function Evaluation
- •14.2.3.9 Imaging Evaluation
- •Evaluation by 3D Visualization
- •14.2.3.10 Surgical Planning
- •14.2.3.11 Surgical Procedure
- •Step 1
- •Step 2
- •Step 3
- •References
- •15.1 Introduction
- •15.2 Clinical Stages
- •15.2.2 Surgical Strategy
- •Tis/T1a Stage
- •T1b Stage
- •Stage T2
- •Stage T3
- •Stage T4
- •15.2.2.2 Lymph Node Dissection Range
- •Stage Tis/T1a
- •Stage T1b
- •Stage T2
- •Stage T3
- •Stage T4
- •15.2.2.3 Extrahepatic Bile Duct Management
- •Stage Tis/T1a
- •Stage T1b
- •Stage T2
- •Stage T3
- •Stage T4
- •15.3.1 T Staging Assessment
- •15.3.1.1 Stage T2
- •MDCT
- •15.3.1.2 Stage T3
- •MDCT
- •15.3.1.3 Stage T4
- •15.3.3 Resectability Assessment
- •15.3.3.1 General Assessment
- •15.3.3.2 Liver Function Assessment
- •15.3.3.3 Virtual Surgery Assessment
- •15.4.1 Surgical Indications
- •15.4.2 Preoperative Preparation
- •15.4.2.3 Preoperative 3D Visualization Evaluation
- •15.4.3 Surgical Procedures
- •15.4.3.1 Resection Range
- •Radical Pancreaticoduodenectomy
- •15.4.4 Surgical Prognosis
- •References
- •16.1 Introduction
- •16.2.2.2 Imaging Diagnosis
- •16.2.2.3 Pathological Diagnosis
- •16.2.2.4 Clinical Staging
- •16.2.3.1 Preoperative Assessment
- •Liver Function Assessment
- •Resectability Assessment
- •3D Visualization Assessment
- •16.2.3.2 Surgical Approach
- •16.2.3.3 Controversial Point
- •Lymphadenectomy
- •Extended Hepatectomy
- •Liver Transplantation
- •Operative Prognosis
- •16.2.4 Multidisciplinary Team
- •16.2.5 Conclusion
- •Notes
- •16.3.4 Surgical Planning Guided by 3D Visualization
- •Type I
- •Type II
- •Type IIIa
- •Type IIIb
- •Type IVa
- •Type IVb
- •Type V
- •16.3.6.2 Typical Case
- •Case 1
- •Case 2
- •Case 3
- •Case 4
- •Case 5
- •16.3.6.4 Lymphadenectomy
- •16.3.6.6 Laparoscopic Exploration
- •16.3.6.7 Intraoperative Frozen Section Consultation
- •16.3.6.8 Liver Transplantation
- •Common Type
- •Type II Variation
- •Type III Variation
- •16.3.10 Other Comprehensive Treatment
- •16.3.11 Other Perioperative Management
- •16.3.11.2 Postoperative Follow-Up
- •References
- •17.1 Introduction
- •17.2.2.1 Perihilar Tumor
- •17.2.2.2 High Biliary Stricture
- •Hepatic Arterial Variation
- •Portal Vein Variations
- •Bile Duct Variations
- •17.3.2 Complex Pathophysiology
- •17.4.1.3 Preoperative Biliary Drainage
- •17.4.2.3 Cholangiojejunostomy
- •17.6 3D Visualization Imaging
- •Viscera Reconstruction
- •Lesion Reconstruction
- •Vascular Reconstruction
- •References

2
tic duct
Rig
and biliary tract
Proper hepatic artery
J. Ouyang et al.
Fig. 1.1 Adult intrahepatic
bile duct cast specimen. (a)
Top view, (b) bottom view
Fig. 1.2 Cast specimen of
adult liver ducts. Note: Green
for biliary tract and hepatic
duct, blue for hepatic vein,
red for hepatic artery, and
yellow for portal vein
Right posterior segment
Right hepatic duct
Right anterior segment
Right anterior segment
Right hepatic duct
ht posterior segment
a
Left lateral segment
Left hepatic duct
Common hepa
Left medial segment
b
Common hepatic duct
Right hepatic duct
Left lateral segment
Left hepatic duct
Hepatic vein
Portal vein
an acute angle with the common hepatic duct. It is usually
formed by the convergence of the right anterior sectoral
ducts (RASD) and right posterior sectoral ducts (RPSD).
Variations of the hepatic duct and its branches are exceedingly common. Accessory hepatic ducts can occasionally be
discovered, mostly an accessary right hepatic duct, which
often exits the liver at the liver hilum and conuent with the
hepatic duct, the cystic duct, or the common bile duct
(Couinaud 1989).
Within the porta hepatis, the hepatic duct, the portal vein,
and the hepatic artery are closely related. Typically, the left
and right hepatic ducts travel in the front, the left and right
hepatic arteries in the middle, and the left and right branches
of the portal vein in the rear. The proper hepatic artery
divides into left and right hepatic arteries before entering the
porta hepatis, but the point at which it gives rise to the left
Hepatic duct
and right hepatic arteries is low; the portal vein bisects into
the left and right branches, and the junction forms at a
slightly higher point; while the union of left and right hepatic
ducts was found to be superior to the hepatic arteries. The
common hepatic duct is usually located in the right anterior
part of the hepatoduodenal ligament; it measures approximately 2–4cm in length with a diameter of 0.4–0.6cm. The
inferior aspect of the common hepatic duct then joins the
cystic duct coming from the gallbladder to form the common
bile duct (Fig.1.3).
1.2.2.2 Gallbladder
The gallbladder is a pear-shaped and thin-walled saccular
structure located in a shallow fossa on the visceral surface of
the liver, in line with the interlobar ssure that separates the
two hepatic lobes. It measures approximately 8–12 cm in

tic duct
Neck
Va
1 Applied Anatomy oftheBiliary Tract
Fig. 1.3 Extrahepatic bile
duct
3
Calot triangle
Cystic artery
Fig. 1.4 Composition of the
ampulla of Vater
of gallbladder
Cystic gall duct
Sphincter of common bile duct
Major duodenal papilla
ter ampulla sphincter
Vater ampulla
Common hepa
common bile duct
Cystic gall duct
Main pancreatic duct
Sphincter of pancreatic duct
Pancreas
length, 3–5cm in diameter, and 40–60ml in capacity when
fully distended. The gallbladder is divided into three sections: the fundus, body, and neck.
The gallbladder fossa projects upward, backward, and to
the left, and eventually tapers at the neck. At the junction of
the neck of the gallbladder and the cystic duct, a dilatation or
pouch may appear, known as ampulla of gallbladder
(Hartmann’s pouch). Gallstones commonly impact this sac,
producing obstruction and acute cholecystitis.
1.2.2.3 Cystic Duct
The cystic duct extends from the neck of the gallbladder. It is
typically 0.3cm in diameter and about 2–3cm long. Spiral
mucosal folds, referred to as valves of Heister, are present in
the proximal mucosa of the cystic duct, which regulates the
bile owing in and out of the gallbladder and prevents the
distortion of the gallbladder duct; while the proximal mucosa
of the common hepatic duct shows a smooth manner.
Gallbladder hydrops can occur when bile duct inammation
causes edema of the Heister valves, or when large stones are
incarcerated.
The cystic duct merges with the common hepatic duct to
form the common bile duct, while the position and entry of
the cystic duct into the ductal system are variable. It can run
anteriorly or posteriorly and enter the left side of the common hepatic duct, it can be fused to the right hepatic duct or
left hepatic duct, it can also run parallel and enter it more
distally.
Calot’s triangle is a triangular space bordered by the cystic duct inferiorly, common hepatic duct medially, and the
inferior edge of the liver superiorly; it is of particular importance surgically because it contains the cystic artery, the right
hepatic artery, and accessory right hepatic duct. This anatomical space requires careful dissection during cholecystectomy to avoid injury (Fig.1.3).
1.2.2.4 Common Bile Duct
The common bile duct is formed by the junction of the cystic
duct and the common hepatic duct. It measures typically
about 7–9cm in length and about 0.6–0.8 cm in diameter.
The duct can be divided into four portions according to its
course and relationships (Fig.1.4).
Supraduodenal Portion
The supraduodenal portion begins at the conuence of the
common hepatic and cystic ducts and ends at ampulla of
Vater in the second part of the duodenum at the major duodenal papilla. This portion lies anterior to the portal vein, to the

4
tic artery
Ga
J. Ouyang et al.
right of the hepatic artery proper, and descends along the
right edge of the hepatoduodenal ligament. This segment is
relatively easy to expose; via which laparoscopic common
bile duct exploration, T-tube drainage, choledochoscopy
with stone extraction, and Roux-en-Y anastomosis are often
performed.
Retroduodenal Portion
The common bile duct passes behind the superior part of the
duodenum, with the inferior vena cava on its posterior aspect
and portal vein and gastroduodenal artery (GDA) on its left.
Pancreatic Portion
The common bile duct descends through a groove placed on
the posterior aspect of the pancreas or within the pancreatic
substance. This portion begins at the head of the pancreas
and ends at the duodenum wall. This segment is difcult to
expose during the operation. In order to reveal it, the posterior peritoneum of the lateral duodenum must be dissected,
and the duodenum and pancreatic head be removed and
turned inward.
Intraduodenal Portion
This course is 1.5–2cm in length, in which the common bile
duct passes obliquely through the middle of the medial border of descending duodenum. In 85% cases, the common
bile duct and main pancreatic duct pierce the duodenal wall
and unite to form a dilated common channel, known as the
ampulla of Vater (Ramesh and Sharma 2014). The ampulla
of Vater protrudes into the duodenum lumen, and the elevation of the duodenal mucosa forms the major duodenal
papilla, opening to the posterior medial wall of the descending duodenum. At the exit, a small complex of smooth muscles, known as the sphincter of Oddi, surround the ampulla,
terminal parts of the common bile duct, and the main pancreatic duct. The duodenal papilla is generally 2mm in diameter, 3mm in height, and 4mm in width, located in the middle
third of the descending duodenum. In another 15–20% cases,
they have separate openings for the bile duct and the main
pancreatic duct (Misra and Dwivedi 1990). The sphincter of
Oddi is a crucial structure regulating the pressure in the bili-
ary system. It controls the openings of the common bile duct
and the pancreatic duct and also prevents the regurgitation of
duodenal contents into the biliary tract.
The main structures of the hepatoduodenal ligament
include the common bile duct, hepatic artery proper, and portal vein. The common bile duct lies in the ligament’s right
edge, the hepatic artery proper lies to the left, and the portal
vein lies posteriorly; hepatic arterial anomalies may occur.
The replaced right hepatic artery usually arises from the
superior mesenteric artery and the gastroduodenal artery,
which has a tremendous guiding value for surgery.
The blood supply of the gallbladder is derived from the
cystic artery, which originates approximately 85% of the
time from the right hepatic artery and most of which commences within the Calot’s triangle. However, there is great
variation in the course and origin of the cystic artery. It may
also arise from the gastroduodenal artery, right, left, and
middle hepatic artery or hepatic artery proper originating
from the superior mesenteric artery (Fig.1.5). Venous drainage is via the cystic veins, which join the right branch of the
portal vein. Note, some parts of the small cholecystic venous
branches enter the liver directly through the liver bed and
ow into the hepatic vein. The blood supply to the hepatic
ducts, cystic duct, and the upper portion of the common bile
duct is the cystic artery. The blood supply to the medial
aspect of the common bile duct is to the right of the hepatic
artery proper. The lower part of the common bile duct is supplied by the branches of the gastroduodenal artery and posterosuperior pancreaticoduodenal artery. Fine branches from
the arteries mentioned above, form a reticular epicholedochal
venous vascular network on the surface of the common bile
duct and anastomose with each other to form plexuses. These
arteries conuence into two axial vessels at the 3 o’clock and
9 o’clock positions of the bile duct wall and have an axial
course supplying the bile duct. The veins of each bile duct
segment converge directly into the portal vein or quadrate
lobe of the liver (Figs.1.6, 1.7, and 1.8).
Lymphatic drainage: Lymph drains into the cystic lymph
node, which empties into the hepatic lymph node. The lymph
nodes of the gallbladder are mainly lymph nodes that meet at
the junction of the cystic duct and the common hepatic duct.
Fig. 1.5 The cystic artery
originating from the right
hepatic artery
Cystic artery
Right hepatic artery
stroduodenal artery
Left hepatic artery
Proper hepatic artery
Common hepa

Right hepatic artery
ry
Ga
3 o'clock artery
Anterior T-shaped arterial
network of the common bile
duct
1 Applied Anatomy oftheBiliary Tract
Cystic artery
Fig. 1.6 Cast anatomy of cystic artery
Fig. 1.7 Blood supply of
common bile duct
5
The lymph nodes in the upper part of the bile duct merge into
the lymph nodes of the gallbladder, the lymph nodes of the
liver, and the lymph nodes of omental foramen. The lymph
of the gallbladder and the lymph of the liver combine and
drain to the lymph nodes next to the common bile duct in the
duodenum, which is accompanied by the hepatic artery to
the peripheral lymph nodes around the celiac artery. The
lymphatics in the lower bile duct are drained to the pancreatic lymph node and then drain along the axis of the hepatic
artery to the lymph nodes around the celiac artery.
Innervation: It mainly refers to the afferent bers of the
sympathetic and vagal nerves in the celiac plexus, both of
which are distributed in the gallbladder and bile duct; with
the branches of the hepatic artery passing through the hepatic
plexus. Parasympathetic stimulation produces gallbladder
contraction and sphincter of Oddi relaxation, allowing bile
outow into the duodenum, while stimulation of the sympathetic nerve has the reverse effect (Zhong 1998).
Right hepatic artery
Gallbladder
Cystic artery
Duct of gallbladder
Common bile duct
stroduodenal artery
Common bile duct
9 o'clock artery
Common hepatic duct
Left hepatic artery
Proper hepatic artery
Common hepatic artery
Pancreas
Superior mesenteric arte
Fig. 1.8 Intrahepatic and extrahepatic biliary system and the accompanying arteries

6
J. Ouyang et al.
The composition of the gallbladder wall:
• Mucosa: The mucosa is lined by columnar epithelial cells
with absorption function and contains specialized tubuloalveolar mucous glands that secrete sticky mucus. The
gallbladder mucosal is variably folded, which increases
the total surface area for inspissating bile.
• Muscularis externa: Consists of the thick inner longitudinal, the outer circular, and the middle elastic brous
tissues.
• Adventitia: Adventitia is made up of a thick layer of connective tissue, and a layer of mesothelium covers adventitia on the free surface.
The composition of the extrahepatic bile duct wall:
• Mucosa: The mucosa contains such mucous cells as goblet cells that secrete mucus.
• Smooth muscle and elastic ber layer: Stimulation causes
spasmodic contraction of the muscle bers.
• Serosa: The serosa is made up of a layer of connective
tissue rich in nerves and blood vessels.
1.2.3 Anatomy oftheBiliary Cast
Tremendous advances in medical technology and update of
medical equipment have driven the eld of modern surgery
forward into the current minimally invasive approaches and
precision procedures. Moreover, the development of surgical
navigation systems, virtual surgery, and robotic surgery have
necessitated examining the distribution of small blood vessels in 3D spaces. Accurate surgical treatment has put forward higher requirements for understanding complex
intrahepatic anatomical structures, and further strengthening
the understanding of it will undoubtedly greatly enhance the
therapeutic effect on biliary diseases.
The development of biliary surgery has beneted from
studies on vascular structures of the liver. The internal vascular and ductal anatomy of the liver is complex (Hjortsj 1951).
In recent years, the trend in biliary tract surgery is toward
minimal invasive, individualized, and delicate procedures,
while precision surgery should be based on advanced anatomical knowledge. Concerning the researches on the anatomy of the liver, the gross anatomy of cadavers, and corrosion
cast methods are primarily used (Spitzer et al. 1996).
Meanwhile, the widespread application of digital technology
and an increasing number of researches into intrahepatic
anatomical structure using these techniques has further deepened people’s understanding of the anatomy of the liver
(Figs.1.9 and 1.10) (Wigmore etal. 2001).
Vascular corrosion casting is a widely used dissection
technique in medical education and clinical research, which
can visualize the complex three-dimensional structure of the
human hepatic vasculature. It resembles casting technology
in the industry. However, it is based on the natural vascular
or cavity structure in viva (such as blood vessels, lymphatic
vessels, ventricles, hepatic ducts, and pancreatic ducts). The
vascular structures are perfused with a xative (such as plastic or denture powder). When the injected substance
becomes hard, the specimen is submersed in a strong acid or
alkali solution. The tissue is subsequently corroded away,
while the hardened cast remains because of its strong acid
and alkali resistant properties. The whole process is known
as vascular corrosion casting. The casting technique dates
back to fteenth to sixteenth century Italy. The famous
painter, Da Vinci, produced a wax cast of cerebral ventricles. Since then, a variety of mold specimens have been produced using materials such as low-melting point alloys and
celluloid. By the 1970s, the casting technique had entered a
new stage of development thanks to the advances in the
modern chemical industry. Many premium-quality plastic
products, such as perchloroethylene and styrene, have been
utilized as lling materials in the casting process. While
perfusing, a low- concentration xative is recommended
since the diameter of the bile duct system is relatively small.
At the rst perfusion, it should be performed after bile is
squeezed out through the common bile duct. The bile duct
system may not be adequately perfused at one time, and in
that case, reperfusion is needed on the post-perfusion day 2
or 3. Anticorrosion and xation are very important, and the
natural shape of the liver should be maintained to avoid
deformation under pressure.
Bile duct and adjacent structures are xed.
1.3 Isolated Biliary Tract andVascular
Perfusion
Studies on intrahepatic vascular structure have aided
advances in biliary tract surgery; further, it has been pushed
into a new stage by dramatic improvements in modern imaging modalities (such as spiral computed tomography (CT),
and MRI). Nonetheless, biliary tract surgery still faces signicant challenges due to the complexity and variability of
intrahepatic vascular structure; and lack of sophisticated
research on and three-dimensional imaging of it. Currently,
with the development of the clinical anatomy of biliary tract
and biliary tract surgery, modern imaging techniques as well
as their mutual integration, studies have achieved the visualization of image dataset and intrahepatic vessels and simulation of biliary tract operations.

Common hepatic Duct
Duct of gallbladder
Right hepatic duct
1 Applied Anatomy oftheBiliary Tract
7
Fig. 1.9 Perfusion of the
gallbladder, bile duct, portal
vein, and artery Note: Green
for the bile duct and hepatic
duct, red for the hepatic
artery, white for the portal
vein
Gallbladder
Duct of gallbladder
a
Right hepatic duct
Left hepatic duct
b
Common bile duct
1.3.1 Intrahepatic Vascular Perfusion
While studying the biliary perfusion, the other three sets of
intrahepatic vasculatures (the hepatic artery, portal vein,
inferior vena cava/hepatic vein) should be properly perfused
as well (Fang etal. 2007). Satisfactory images of the pipelines should be generated during the CT scan. Based on CT
values, the four vasculatures may need to be extracted,
removed, and 3D reconstructed separately. Such objectives
can be achieved by the following two protocols.
Technique
Duct of gallbladder
Gallbladder
c
powder. Though perfused satisfactorily, the pipelines are
incapable of being identied, extracted, and 3D reconstructed because they possess the same CT value on CT
images and the thin hepatic artery and bile duct system. The
entirety of the portal and hepatic veins within the hepatic
lobes and segments can be displayed during 3D reconstruction when the perfusion of the portal vein and hepatic vein is
satisfactory, and thin-slice CT images are clear.
centrations of vermilion powder. Because of the concentra-
Left hepatic duct
Common hepatic duct
Firstly, the four pipelines are injected with 10% vermilion
Secondly, four pipelines are injected with different con-

8
Hepatic artery
Biliary system
J. Ouyang et al.
Fig. 1.10 Perfusion of the
gallbladder, biliary tract, and
hepatic artery. (a) Anterior
view, (b) posterior view.
Note: Green for the
gallbladder, biliary tract, and
hepatic duct; red for the
hepatic artery
Hepatic artery
Biliary system
a
Gallbladder
b
Hepatic artery
Gallbladder
tion differences, CT showed different CT values during
scanning. According to the differences, the four pipelines are
3D reconstructed. Note, at the rst perfusion bile should be
squeezed out through the common bile duct, since the hepatic
artery and bile duct system are relatively small in diameter.
The bile duct system may not be adequately perfused at
one time, and in that case, reperfusion is needed on the postperfusion day 2 or 3. Anticorrosion and xation are vital. The
natural shape of the liver should be maintained to avoid
deformation under pressure, lest distortion of the mold during casting occurs. The portal vein and inferior vena cava are
relatively thick and even more so in fresh specimens. In the
casting process of large vessels, it is better for the vessels to
be thick and sparse, rather than to be thin and dense. To
reduce the blood vessel elasticity, traditional anticorrosive
methods should be utilized for vascular xation. During the
anticorrosive process, attention must be paid upon leakage of
perfusate from vasculature surrounding the liver. In the event
of such leakage, blood vessels can be ligated using hemostatic forceps or wire sutures. Since the portal vein and inferior vena cava are relatively thick, the lling agent must be
strong and non-brittle to support the weight of the liver. The
effect of using the rapid repair powder and liquid for acrylic
denture as lling agents is rather satisfactory. The model of
the human body, diaphragm, and abdominal cavity is con-
structed out of berglass. Then, the liver is placed in the
abdominal cavity, in an anatomical position similar to that of
the human liver and examined with a thin layer CT scan and
MRI, which can display clear intrahepatic vascular structures and achieve strong stereoscopic effects.
1.3.2 Data Acquisition
1.3.2.1 Collection andDissection ofBiliary
Specimens
Cadaver specimens were obtained from the Institute of
Clinical Anatomy of Southern Medical University. The ligamentum teres hepatis, falciform ligaments, left and right triangular ligaments were resected, and the liver was mobilized.
The hepatic artery, portal vein, and common bile duct were
severed horizontally at the duodenal bulb, and the inferior
vena cava was severed above the level of the right renal vein.
The vena caval foramen of the diaphragm was opened, the
superior and inferior vena cava severed, and the liver procured intact. Then, the liver was perfused through the portal
vein with saline or tap water until the color of the liver
changed or partially whitened. The broken end of the infrahepatic vena cava was sutured continuously. Small diameter
cannulae were inserted in the hepatic artery and common

1 Applied Anatomy oftheBiliary Tract
9
bile duct and ligated with sutures. Large diameter cannulae
were inserted in the portal vein and suprahepatic vena cava
and ligated also. To avoid perfusate leakage while perfusing,
small blood vessels in the hepatic hilar area were ligated with
silk thread.
1.3.2.2 Bile Duct Perfusion
Two perfusates (yellow) of different concentrations of vermillion powder were prepared:
• 10% vermilion powder, perchloroethylene, and yellow oil
paint
• 5% vermilion powder, perchloroethylene, and yellow oil
paint
1.3.2.3 Hepatic Artery Perfusion
Two perfusates of different concentrations were prepared:
• Red perfusate: 10% vermilion powder, perchloroethylene, ethyl acetate, and red oil paint.
• Dark red perfusate: 20% vermilion powder, perchloroethylene, ethyl acetate, and red oil paint.
1.3.2.4 Specimen Perfusion Fixation
The specimen, which was perfused through the hepatic artery
and bile duct were submerged in gauze saturated with water,
and a 10% formalin solution was infused through the portal
vein. The portal vein and inferior vena cava were clamped
once formalin started to ow out through inferior vena cava.
1.3.2.5 Perfusion andFixation ofthePortal Vein,
Inferior Vena Cava, andHepatic Vein
1.4 Digitalized Biliary Tract andBlood
Vessels
1.4.1 Liver Dissection after Biliary Tract Perfusion
The isolated liver model perfused by four perfusates with
respective colors, was embedded with blue gel. Eight brownred markers were placed surrounding the liver as image registration points. The liver was stored in a freezer for 3 weeks
at a temperature of −25°C and subsequently transferred to
the laboratory at −27 °C. The liver was then serially sectioned at 0.2mm intervals with the JX1500A vertical milling
machine. The serial cross-sections were photographed using
a high-resolution digital camera to produce anatomical
images, which were uploaded to a computer.
1.4.2 Acquisition andAnalysis ofSectioned
Images
Cross-sectional pipelines were well displayed, and all pipelines were clear. The inferior vena cava and hepatic vein system were black, and the portal vein system was orange. The
hepatic artery, which runs alongside the portal vein was red.
The hepatic duct and the gallbladder were dark green. The
peripheral hepatic vein and portal vein were clear.
Intervals of the anatomical images were 0.2mm, and 910
pairs of cross-sectional images were acquired. The data le
of each section occupies 17.5MB, and the le size of the
liver dataset was 15.3GB in total (Fig.1.11).
Perfusion andFixation ofthePortal Vein
Two perfusates of different concentrations were prepared:
• Brown perfusate: 60g of rapid repair powder for acrylic
denture, 60ml of rapid repair liquid for acrylic denture,
12g of 10% vermilion powder, 15ml of dibutyl phthalate,
and brown oil paint.
• Yellow perfusate: Yellow oil paint and the other components were the same as above.
Perfusion andFixation oftheInferior Vena Cava/
Hepatic Vein
Two perfusates of different concentrations were prepared:
• Blue perfusate: 60 g of rapid repair powder for acrylic
denture, 60ml of rapid repair liquid for acrylic denture,
12g of 10% vermilion powder, 15ml of dibutyl phthalate,
and brown oil paint.
• Light red perfusate: White oil paint, 12g of 8% vermilion
powder, and the other components were the same as the
above.
1.4.3 3D Reconstruction ofImages
Three-dimensional reconstruction of the cross-sectional
images obtained through milling was achieved after registration and segmentation. These images were converted into
BMP format to facilitate the subsequent processing
(Fig.1.12).
1.4.3.1 Image Registration After Bile Duct Perfusion
Image registration was conducted by external point force
combined with moment-to-force. The landmarks preembedded surrounding the liver were set as registration
points. The image registration was performed based on the
relatively xed positions between the liver and those landmarks. The specic methods are:
• In the source image, the registration points were displayed
on a blue background presenting as dark red point set
scattered around the image. These point sets were identied according to the color and their position features.

10
Right hepatic artery
Common hepatic duct Common bile duct
Hepatic artery
Portal vein
J. Ouyang et al.
Fig. 1.11 Cross-sectional
images of the hepatic hilum
a
Right hepatic vein
Right portal vein
Right hepatic duct
Portal veinHepatic artery Gallbladder
Hepatic artery
Right portal veinLeft hepatic vein
b
Common hepatic duct
c
Right hepatic duct
Portal vein
Right hepatic artery
Hepatic vein
GallbladderCommon bile duct
Hepatic vein
Right portal vein
GallbladderCommon bile duct

y
Hepa
1 Applied Anatomy oftheBiliary Tract
Fig. 1.12 The display
window and 3D reconstructed
liver
11
Fig. 1.13 Image registration
of the sectioned images after
intrahepatic pipe perfusion
(the white arrow points to the
registration point)
tic artery
• After a comparison of the source and target images, translation and scaling of each image should be performed so
that each point of one image can be mapped to a corresponding point of another image.
• The area containing the liver was sheared from the source
image (Fig.1.13).
1.4.3.2 Image Segmentation After Bile Duct
Perfusion
Image segmentation is the process of partitioning an image
into multiple meaningful segments according to certain principles. Segmentation of milled images is the extraction of
tissues from the liver. The image data of liver parenchyma,
hepatic veins and inferior vena cava, portal veins, hepatic
artery and gallbladder, and hepatic artery were respectively
segmented, and their contour line was extracted.
Hepatic arter
1.4.3.3 3D Reconstruction oftheBiliary Tract
• Three-dimensional surface rendering reconstructions
were generated from image sequences using the
Visualization Tool Kit (VTK). Specic methods were:
contour lines were extracted into several of these tissue
types on every image; the region between contour lines of
adjacent images were lled with at triangles, which
formed a banded ring; the 3D surface of the object was
generated from a set of contour lines.
• The reconstructed liver model was displayed using the
surface description method. The model contains ve
parts, including the liver, the hepatic vein and inferior
vena cava, the portal vein, the hepatic ducts and gallbladder, and the hepatic artery. Also, a Windows PC-based
3D visualization demonstration system and Windows
operation system of liver were developed. By clicking on
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