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12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
287
• Freeing of the 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 left
hepatectomy.
• ICG uorescent imaging technique was used to detect
bile leakage on the right liver section (Resources 12.3,
12.4, and 12.5) (Figs.12.80, 12.81, 12.82, 12.83, 12.84,
and 12.85).
For Patients withStones Distributed inSegments II
andIII andLeft Hepatic Duct Stenosis
• Cholecystectomy.
• Choledocholithotomy.
• Resection of hepatic segments II and III.
• Rapid intraoperative pathological examination of multipoint biliary ducts in the hepatic section.
Fig. 12.77 Anatomy of the right portal vein and control
• Hepatolithiasis was removed through Section IV of the
bile duct.
• Left hepatobiliary stenosis was reconstructed.
• Choledochoscope (soft/hard) was used to detect segment
IV of the bile duct and Oddi sphincter.
• Choledochojejunostomy: determined by intraoperative
choledochoscopy and Oddi sphincter function
(Figs.12.86, 12.87, 12.88, 12.89, 12.90, and 12.91).
12.10.3 Liver Resection inSpecial Cases
Guided by 3D Visualization
Technology
The removal of the lesion through regular hepatectomy is
difcult for patients with: diffuse stones in the left and right
livers, and older age, recurrent cholangitis, multiple operations, poor general condition, insufcient residual liver volume, and insufcient liver reserve function, and even for
patients who cannot tolerate extensive hepatectomy, especially in hospitals where the technical expertise is relatively
limited. How to avoid multiple operations on these patients
as far as possible, and strive for radical treatment in a single
operation, is a difcult problem. Surgical strategy included
perioperative safety measures to enhance liver reserve
function and the general whole-body condition. On this
foundation and guided by 3D visualization technique, the
method of combining regular hepatectomy, irregular hepatectomy, and choledochoscopic soft/hard lithotripsy was
adopted in order to realize the basic principles of treating
hepatolithiasis; while preserving remnant liver tissues to the
greatest extent, to enable patients to recover safely.
Cases 1 and 2: Patients with stones diffused in the left and
right liver and not suitable for regular hepatectomy and segmental resection for various reasons.
Fig. 12.78 Atrophy of the
right liver. ICG uorescent
imaging clearly shows the
dividing line of the left and
right liver
288
Q. Lu et al.
12.10.3.1 Contraindication
• Patients with obvious bleeding and coagulation
dysfunction.
• Liver function Child-Pugh class C.
• Unable to tolerate general anesthesia.
12.10.3.2 Preoperative Preparation andImage
Evaluation
Same as before.
12.10.3.3 Surgical Procedures
Case 1
Diagnosis Choledocholithiasis, L
.
VI, VII
II~VII
, S
, D
left
IV, V, VII
, A
II, III,
Surgical Procedures
• Such patients often have 2–3 or more biliary tract operations and severe hilar adhesions. Therefore, the hilar bile
duct should be found along the right side of the liver.
Sometimes, partial resection of the quadrate lobe of the
liver or splitting of the median hepatic ssure is necessary
to nd the dilated bile duct above the hilar part.
• Incision of the common bile duct for removal of a
gallstone.
• Resection of hepatic segments II and III.
• Intraoperative frozen examination of the bile ducts on the
left liver section.
• Choledocholithotomy through segment IV.
• Reconstruction of the biliary stricture is needed for
patients with left hepatic biliary stricture.
• Right atrophic segment/area resection.
• Intraoperative frozen examination of the bile ducts on the
right liver section.
• Removal of stones through the right hepatic section and
hilar bile duct.
• Reconstruction of the biliary stricture is needed for
patients with right hepatic biliary stricture.
• Soft/rigid choledochoscopy was used to explore the bile
duct of segment IV, right hepatic duct, extrahepatic bile
duct, and Oddi sphincter.
• Cholangiojejunostomy (Resources 12.6 and 12.7)
(Figs. 12.92, 12.93, 12.94, 12.95, 12.96, 12.97, and
12.98).
Fig. 12.79 Right hemihepatectomy and choledochojejunostomy
Fig. 12.80 CT showing left
hepatolithiasis
Case 2
Diagnosis Hepatolithiasis, L
V, VI, VII, VII
, S
right
, D
V, VII, VII, AVI
.
The left hepatic portal
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.81 3D visualization of the left hepatolithiasis is adjacent to the
middle hepatic vein. Type L
II, III, IV
, S0, D
left hepatic duct, II, III, and IV, C
0
vein
The left hepatic
artery
289
Note: Preserve multipoint biopsy of the lateral bile duct
for rapid pathological examination during surgery to exclude
malignant changes (Figs.12.99, 12.100, 12.101, and 12.102).
12.10.4 Targeted Lithotripsy andStone
Extraction Through aSinus
Choledochoscope (Hard Endoscope)
Guided by 3D Visualization
12.10.4.1 Indications
Patients with a history of biliary tract surgery, residual
stones, recurrent hepatolithiasis, and biliary duct stent or
drainage tube, can have targeted hard endoscopic lithotripsy
and stone removal through the sinus duct guided by 3D
visualization.
12.10.4.2 Contraindication
• Patients with obvious bleeding and coagulation
dysfunction.
• Child-Pugh class C grade of liver function.
• Those who cannot tolerate general anesthesia.
12.10.4.3 Preoperative Preparation
andImaging Evaluation
• High-quality CT image data of hepatolithiasis and hepatobiliary duct stones were routinely collected before the
operation for 3D visualization analysis.
• Direct cholangiography was performed through various
drainage tubes and supporting ducts of the biliary tract.
• MRCP was performed routinely before the operation.
Fig. 12.82 Anatomy of the rst hepatic hilum, left hepatic artery, left
hepatic portal vein, and control them
Surgical Procedures
• Removal of the gallbladder.
• Choledocholithotomy.
• Liver resection of the atrophic segment VI.
• Intraoperative frozen examination of the bile ducts on the
liver section.
• Removal of stones through the right hepatic section.
• Reconstruction of the hepatic biliary stricture.
• Soft/rigid choledochoscopy was used to explore the right
hepatobiliary duct and Oddi sphincter.
• Roux-en-Y anastomosis: based on intraoperative choledochoscopy and sphincter of Oddi function (Resources
12.2 and 12.3).
12.10.4.4 Surgical Procedures
• The Richard Wolf choledochoscope was used for the
operation.
• Individualized targeted lithotripsy was performed under
the guidance of the MI-3DVS.
• General anesthesia with tracheal intubation.
• The initially placed biliary drainage catheter was pulled
out, and the length of the body was recorded. The patchy
guidewire was inserted into the dilator and sheath tube
from the sinuses, and the indwelling dilator and sheath
tube were placed along the patchy guide wire to reach the
common hepatic duct or intrahepatic bile duct, leaving the
sheath tube and assistant xation.
• The rigid mirror was connected with the adjustable pressure water pump, and 0.9% sodium chloride was used as a
ushing solution. The rigid mirror reached the target bile
duct under the guidance of the 3D model. Then a pneumatic-ballistic lithotripter was placed, and stones larger
290
Fig. 12.83 Severe left
hepatic atrophy; ICG
uorescent imaging clearly
showing the left and right
hepatic dividing lines
Q. Lu et al.
• Intrahepatic strictured bile ducts were dilated with soft
dilators such as biliary balloons. For strictured bile ducts
with solid scars, an electric knife was used to cut them off.
After dilatation, the distal bile duct supporting beyond the
strictured segment was placed.
• Finally, extrahepatic bile duct stones were explored and
removed, and the function of Oddi sphincter was
observed.
• T-tube and drainage tubes were retained.
Fig. 12.84 Anatomic left hemihepatectomy
than 10mm were crushed with the pneumatic ballistics.
The ballistic pressure was automatically regulated by the
pump, ranging from 0.2 to 0.4 MPa. Stones were then
removed by grasping forceps or Cook wire basket. Some
of the smaller sediments washed out through the sheath
tube with the owing water. Biliary ducts of grade IV and
above or with small bifurcation angle were removed by
Cook’s basket or ushing and aspirating with water.
12.10.4.5 Attention
• During the lithotripsy procedure, keep the hard lens inside
the sheath pipe, and the procedure can be excited only
when the stone is in contact with the gravel road. The
gravel rod should be placed in the center of the stone, not
in the ssure of the stone or between the stone and the bile
duct wall. This helps avoid hemobilia caused by bile duct
injury by the hard choledochoscope.
• In the course of water ushing, the water pressure should
be adjusted according to the degree of biliary inammation in individual patients. This helps to avoid postoperative infections as it can prevent bacteria from entering the
blood due to excessive water pressure.
• For stones larger than 10mm in diameter, they should
not be forced to take out by lithotripters or Cook basket
alone, so as to avoid hemobilia caused by laceration on
mucosa.
• During the whole lithotripsy process, the total water
ushing volume should be controlled at 24,000 ml to
27,000 ml to avoid water intoxication (Figs. 12.103,
12.104, and 12.105).
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.85 ICG uorescent
imaging was used to detect
biliary leakage in the right
liver section
291
12.10.5.2 Contraindications
Patients with apparent coagulation dysfunction; liver function Child-Pugh class C; inability to tolerate general
anesthesia.
Fig. 12.86 CT shows stones are mainly distributed in segments II, III
bile duct, and atrophy of the left lateral hepatic lobe
12.10.5 Open Liver Resection Combined
withTargeted Lithotripsy Under
Choledochoscope (Soft/Rigid)
Guided by 3D Visualization
12.10.5.1 Indications
• Abdominal adhesions caused by previous abdominal
surgery.
• Severe, multiple stenoses, or liver metastasis of the hilar
biliary tube that requires bile duct plastic surgery.
• Hepatectomy is necessary when there is atrophy of a liver
region or segment.
• Preoperative image evaluation and biochemical examina-
tion indicative of cholangiocarcinoma.
• Laparoscopic hepatectomy or segmental resection is not
available.
12.10.5.3 Surgical Procedures
• For the patients undergoing an operation for the rst time,
cholecystectomy and common bile duct exploration
should be performed rst.
• For those who have undergone biliary surgery many
times, the hilar bile duct must be found along the right
hepatic surface because of severe hilar adhesions.
Sometimes, the partial resection of the hepatic lobe or
splitting of the median hepatic ssure is required to nd
the dilated bile duct above the hilar.
• The bile duct is cut for stone removal.
• The corresponding liver segment or area resection is performed according to the clinical classication and the
need for the disease.
• Rapid pathological examination of the multipoint intraoperative bile duct in the liver.
• Cholangiolithiasis removed through the hepatic segment
section.
• Plastic treatment of hepatobiliary stricture.
• Choledochoscope (soft/hard) exploration of the bile duct.
• Select the appropriate dilator and sheath tube according to
the thickness of the bile duct. The lithotripsy and netbasket stone removal methods are the same as the 3D
visualization technique to guide targeted hard endoscopic
lithotripsy and stone removal through the sinus duct.
• Finally, the extrahepatic stones are explored and removed.
If the Oddi sphincter function is normal and biliary hard
mirror can enter the duodenal cavity, T-tube and drainage
tube should be indwelled. If Oddi sphincter is loose, cho-
292
y
Fig. 12.87 3D modelling
and digital clinical
classication: L
, D
hepatic duct
II ad III
II and III
, C
, S
left
0
Q. Lu et al.
The right hepatic arter
Fig. 12.88 The right hepatic artery crosses over the common hepatic
duct, and the actual operation is consistent with the 3D visualization
display
ledochojejunostomy should be performed. The abdominal cavity is closed after washing (Resource 12.4)
(Figs.12.106, 12.107, 12.108, 12.109, and 12.110).
12.10.5.4 Attention
• The specic technical operation precautions for choledochoscopy (soft or hard mirror) targeting gravel and stone
removal are the same as for Sect. 12.10.4.
• Before hepatolithiasis, temporary lling of the lower segment of the common bile duct with a gauze strip can
reduce the amount of ushing uid entering the intestinal
tract through the lower segment of the common bile duct.
At the same time, continuous suction of the overowing
lavage uid by a suction device can reduce the absorption
of water and avoid the occurrence of postoperative water
intoxication.
12.10.6 Percutaneous Transhepatic
Choledocholithotripsy Guided by 3D
Visualization intheTreatment
ofHepatolithiasis
12.10.6.1 Indications
• Recurrence of intrahepatic cholelithiasis after repeated
operations, including biliary and intestinal drainage.
• Intrahepatic and extrahepatic bile duct stones that cannot,
should not, or patients who are reluctant to take other
technical treatment after multiple operations.
• The bile duct dilates above 0.3 cm. In principle, the
thicker the bile duct is, the easier it is to puncture
successfully.
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.89 3D modelling
shows that the stones are
located in segments II and III;
stenosis of the left hepatic
duct
293
Fig. 12.90 Biliary lithotomy through liver section of segment IV; plastic surgery for hepatic duct stenosis
Fig. 12.91 No residual calculi were found by postoperative direct
cholangiography
294
Fig. 12.92 3D visualization
displays calculi in segments II
and III, and parts in segment
IV; the left hepatic lobe
atrophy, and there is no
atrophy of the liver tissue in
segment IV; stones
distribution in segments VI
and VII, and hepatic duct is
accompanied by hepatic
atrophy. In this case, regular
liver resection of segments II
and III, irregular liver
resection of segments VI and
VII should be performed. It is
of great value to the function
of postoperative residual liver
tissue. The individual surgical
decision fully demonstrates
the advantages of 3D
visualization
Q. Lu et al.
Fig. 12.93 Liver resection of segments II and III
Fig. 12.94 Liver resection of segments VI and VII
ducts
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.95 3D visualization
shows the relationship
between dilated bile duct,
hepatic artery, and portal vein
295
Fig. 12.96 3D visualization
displays the size, shape,
distribution of stones, and
their relationship to the portal
vein; digital type: L
D
, C
II–VII
0
II–VII
, S0,
The dilated biliary
and calculus
The portal vein
296
Fig. 12.97 Liver resection of segments II and III, choledocholithotomy via left hepatic cross section
Q. Lu et al.
Fig. 12.99 Calculus in the right liver, right hepatic duct stricture associated with intrahepatic bile duct dilatation
Fig. 12.98 Irregular partial liver tissue in segment VI, and lithotomy
via right hepatic cross section
• In patients with intrahepatic cholelithiasis complicated
with biliary stricture, or patients who have difculty in
ERCP catheterization or failure in operation.
• Simple reversible stricture of the intrahepatic bile duct.
12.10.6.2 Contraindications
• Obvious bleeding and coagulation dysfunction.
• The patient who was in poor condition had apparent cardiopulmonary dysfunction, could not tolerate surgery or
was in critical condition.
• Non-dilatation of the intrahepatic bile duct.
• Liver failure.
12.10.6.3 Preoperative Imaging Evaluation
CT, MRCP, or 3D visualization evaluation.
12.10.6.4 Surgical Procedures
• Percutaneous transhepatic puncture of target bile duct
under epidural anesthesia or general anesthesia was performed under ultrasound localization.
Fig. 12.100 Cholangiolithotomy via right hepatic cross section
• The super-smooth guide wire was put back into the
bile, and the 8-16F dilator was inserted through the
guidewire to expand in turn, and then sent to the sheath
tube through the dilator to establish an operational
channel.
• Then the rigid choledochoscope was used to direct the
target bile duct through the sheath tube, and the adjustable
pressure perfusion pump was used to infuse normal saline
into the target bile duct continuously. After the stones
were located, they were removed by using a net basket, or
by clamping or ushing with water after lithotripsy.
Lithotripsy and 3D visualization technique were used to
guide the target lithotripsy with a hard endoscope through
the sinus tract.
• A drainage tube was inserted into the sinus before the
operation.