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12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
277
c
Fig. 12.55 (continued)
3D printing technology is restricted by factors such as
picture quality of CT and MRI, printing type, and printing
materials. Its wide application in the clinic needs to be further explored. See Chap. 5, 3D Printing Technology, and its
application in biliary surgery for details.
12.10 Precise Treatment ofHepatolithiasis
Guided by 3D Visualization
Technology
At present, surgery is the main treatment for hepatolithiasis.
Because of the wide distribution of stones, the different locations and degrees of bile duct stricture and dilation, the operation methods are various. Meanwhile, some patients with
long-term pathological changes may suffer from atrophy or
hypertrophy of liver parenchyma, complicated by biliary cirrhosis, portal hypertension, biliary tract infection, and liver
abscess, or even have stones associated with intrahepatic bile
duct cancer, which further leads to the complexity and variety of surgical schemes. Based on the reasons above, this
section elaborates on the individualized treatment of hepatolithiasis guided by 3D visualization in different scenarios.
12.10.1 Targeted Lithotripsy
forHepatolithiasis Under
Laparoscopy andCholedochoscopy
Assisted by 3D Visualization
There is a strong segmental distribution of stones in the
liver. It is generally believed that only after removing the
hepatic parenchyma containing stones, can the stones be
completely removed, and the lesions cleared. The diagnostic value of CT, MRCP, and ERCP for hepatolithiasis is
described in detail in Sect. 12.1. From the 3D visualization
model, the images of hepatobiliary stones, which are completely faithful to the patient’s real situation, can be
obtained, and the location, size, and quantity of the stones
can be determined. The course of the bile duct, the location,
extent, and length of the stricture, and its position relative
to the whole liver is clear at a glance; 3D visual classication can clearly dene the liver segments involved in
regional and diffuse lesions and distinguish narrow bile
duct from absolute stricture. Thus, the accurate diagnosis
of hepatolithiasis can be realized, which is helpful in guiding the formulation of the surgical plan. It can greatly
improve the pertinence of and reduce the unpredictability
278
Q. Lu et al.
a
b
Fig. 12.56 (a) Import stitches in FreeForm Model System; (b) suture the left hepatic duct; (c) suture the severed end of the left hepatic artery and
the left portal vein
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
279
c
Fig. 12.56 (continued)
Fig. 12.57 Suture the left
hepatic duct, left hepatic
artery, and left portal vein
280
Fig. 12.58 Magnied view
of the left liver section
Q. Lu et al.
Fig. 12.59 Import the virtual scalpel and activate the biliary tract
Fig. 12.60 Stone forceps are used to remove bile duct stones
ab
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.61 Left hepatolithiasis is shown. The route of cutting the left
liver is determined when the liver transparency is 0.5
281
of the operation. The auxiliary treatment technique can
realize the principle of “removing the lesions, extracting
the stones, relieving the obstruction, completing drainage,
preventing recurrence, and protecting function” in the treatment of hepatolithiasis.
In recent years, 3D laparoscopy has been widely used
because of its high resolution and good depth of eld, which
is benecial to accurate anatomical localization, identication of various deep hepatic duct structures, ne operation,
and intraoperative bleeding control. The application of minimally invasive techniques such as 3D laparoscopy and hard
choledochoscope has changed the huge physiological and
psychological trauma on patients caused by traditional surgical procedures through minimally invasive mini incision.
Although the hard choledochoscope cannot be bent and it is
difcult to explore the intrahepatic bile duct with a wide
angle, it has more advantages compared with the electronic
choledochoscope:
• The hard choledochoscope has a shorter body and ner
diameter. It is simple to operate and can be used to explore
the bile duct branches III and IV, allowing a wider scope
of stone extraction.
Fig. 12.62 (a) Begin by cutting the liver along a dened path (b) Left hepatic vein is sutured when the liver transparency is 0.5
282
Q. Lu et al.
ab
c
Fig. 12.63 (a) The process of cutting when the liver transparency is 1;
(b) the bile duct was opened and dilated for lithotomy when the liver
transparency was 1; (c) during the resection of liver parenchyma, the
• For some large stones, it is difcult to remove them only
by using lithotripter forceps or Cook baskets, and there is
a risk of bleeding caused by tearing the bile duct mucosa.
At this time, pneumatic ballistic lithotripsy can be used to
remove the stones easily without thermal effect, and the
damage is slight.
• The high pressure of hard endoscope irrigation of the bile
duct is helpful for the safe and rapid discharge of crushed
stones.
left hepatic artery, the left portal vein, and the left hepatic duct were
activated to cut off the left hepatic parenchyma
• Continuous suction of negative pressure is helpful for
the timely discharge of contaminated bile and residual, which effectively reduces the bacterial entry into
the blood during the operation and reduces the complications such as biliary tract infection. Thus, the internal environment for the recurrence of stones was
cleared, and the high recurrence rate of stones was
reduced.
• It is relatively cheap and easy to popularize.
ab
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.64 The left liver section was observed when the liver transparency was 0.5
283
Fig. 12.65 Suture the broken end of the left hepatic duct, left hepatic
artery and left portal vein, and the wound surface of the liver was
sutured
Fig. 12.66 (a) Right hepatic resection line was determined when the liver transparency was 0.5; (b) liver cutting process when the liver transpar-
ency was 1
284
Q. Lu et al.
Fig. 12.67 The dilated bile duct was opened to extract the stone when
the liver transparency was 1
Fig. 12.68 During the resection of liver parenchyma, the right hepatic
artery, the right portal vein, the right hepatic vein, and the right hepatic
duct were activated to cut off the right hepatic parenchyma
Fig. 12.69 Lithotomy via right hepatic section
Fig. 12.70 Suture the broken end of the right hepatic duct, right
hepatic artery and right portal vein, and the wound surface of the liver
ducts
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
285
Fig. 12.71 Jejunum was cut off for choledochojejunostomy
a
b
Fig. 12.74 3D printed model of complex hepatolithiasis. Note: (1)
Dark blue: hepatic vein; (2) red: hepatic artery; (3) light blue: portal
vein; (4) green: dilate bile duct; (5) white: stone
The hepatic vein
The dilated biliary
and calculus
The portal vein
The hepatic vein
The dilated biliary ducts
and calculus
The portal vein
The hepatic artery
Fig. 12.72 Choledochojejunostomy
Fig. 12.73 Choledochojejunostomy
The accurate operation was realized through 3D visual-
ization guided targeted lithotripsy for hepatolithiasis under
3D laparoscopy and choledochoscopy, and the residual stone
rate and recurrence rate were reduced. The combination of
the three techniques further promotes the advantages of minimally invasive technique: through 3D laparoscopy, a highresolution surgical vision of the abdominal cavity can be
obtained from a small incision, which makes the operation
more precise and helps to reduce local injury. It is convenient
and fast to establish the passage through the original puncture hole into the sheath tube for the entry and exit of the
hard choledochoscope. The application of choledochoscopy
overcomes the blindness and limitation of traditional bile
duct exploration. Combined with a 3D visual image, the
lesion site can be reached quickly and clearly; and combined
with various stones removal methods, it is helpful to thoroughly and repeatedly remove stones, and relieve the stenosis. On the pathological level, choledochoscopy is also
benecial for obtaining a biopsy of living tissues during surgery, to obtain pathological information more quickly and
accurately, and to understand other pathological conditions
comprehensively. During the operation, gauze packing is
used to block the lower part of the common bile duct, which
can reduce the absorption of water and toxin and ensure the
safety of the operation.
To sum up, 3D visualization assisted targeted lithotripsy
for hepatolithiasis under 3D laparoscopy and choledochoscopy provides a safe and effective approach, and an important
technique of digital minimally invasive surgical treatment.
286
The right hepatic artery
Q. Lu et al.
12.10.2 Anatomical or Regular Hepatectomy Guided by 3D Visualization
According to the pathological basis that hepatolithiasis is a
type of strict intrahepatic segmental lesion, Professor
Zhiqiang Huang rst proposed in 1958 to treat hepatolithiasis with regular hepatectomy (1959). Since then, the clinical
practice of surgical treatment of hepatolithiasis for nearly
half a century has conrmed that among the treatment principles of “relieving the obstruction, removing the lesions,
and completing the drainage”; regular hepatectomy, which
can truly achieve the goal of “removing the lesions,” is the
most important and core technique in the treatment of
hepatolithiasis.
However, in patients with complicated hepatolithiasis,
the liver is often distorted and transposed, and the rate of
variation associated with blood vessels and bile ducts is
very high. It is difficult to obtain ideal portal vein and
hepatic vein morphology in existing imaging examinations, so the failure of some cases to follow conventional
Couinaud segments poses a challenge for regular hepatectomy. Whereas 3D visualization provides a solid and
reliable 3D stereoscopic imaging technique for anatomical or regular hepatectomy; because of the relationship
between the portal vein and hepatic vein in patients with
various types of hepatolithiasis, and its relationship with
the diseased bile duct and stones; can be clearly
displayed.
12.10.2.4 Surgical Procedures
Tracheal intubation combined with general anesthesia.
For Anatomical Right Hemihepatectomy
• The rst hepatic portal was dissected, and the right portal
vein and right hepatic artery were separated and temporarily controlled or ligated.
• Free ligaments around the liver.
• Common bile duct exploration.
• ICG uorescent imaging technique can be used to determine the cutting line of the liver in hospitals where conditions permit.
• The other steps are the same as those for the right
hepatectomy.
• ICG uorescent imaging technique was used to detect
bile leakage on the left liver section (Resources 12.1 and
12.2) (Figs. 12.75, 12.76, 12.77, 12.78, and 12.79).
For Anatomical Left Hemihepatectomy
• The rst hepatic portal was dissected, and the left portal
vein and left hepatic artery were separated and temporarily controlled or ligated.
12.10.2.1 Indications
• Child-Pugh class A hepatic function patients who need
segmental/regional hepatectomy.
• The corresponding hepatic lobectomy or segmental hepatectomy should be performed, if there is liver atrophy or
corresponding segmental biliary stricture, no matter
where the stones are located in the liver.
• Intraoperative choledochoscopy and Oddi sphincter
function determine whether to perform cholangiojejunostomy.
12.10.2.2 Contraindications
• Patients with obvious bleeding and coagulation
dysfunction.
• Liver function Child-Pugh class C.
• Inability to tolerate general anesthesia.
12.10.2.3 Preoperative Preparation
andImaging Evaluation
High-quality CT images of liver and bile duct stones were
collected before operation for 3D visual evaluation, liver
segmentation, and volume calculation.
Fig. 12.75 3D visualization shows right hepatolithiasis, right hepatic
atrophy, compensatory hypertrophy of the left liver. Digital diagnosis:
LV~VII, S
Fig. 12.76 Anatomy of the rst hepatic hilum, right hepatic artery
transection of the common hepatic duct
right hepatic duct
, D
V~VII
, C0