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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_585_Библиотеки_им_академика_М_И_Перельмана.pdf
calculus
c
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
The right anterior
segmental bile duct
297
The residual intrahepati
stones
Fig. 12.101 Right hepatic biliary stricture with right anterior and posterior bile ducts opening
Fig. 12.102 Hard endoscopic lithotripsy
The hepatic vein
The dilated biliary
ducts and
Fig. 12.103 3D visualization shows intrahepatic bile duct stones with
indwelling biliary support tube
• Such patients can be treated by ultrasound-guided staging: (a) 3D visualization technique can guide percutaneous transhepatic cathedral drainage (PTCD). The sinus
tract was dilated once after 1 week, then expanding to
about 16 Fr in 2weeks; one-stage puncture, catheterization, and lithotripsy can also be performed; (b) 3D visualization technique is used to guide the target lithotripsy of
choledochoscope. The patients were treated in stages
Fig. 12.104 Preoperative direct cholangiography of the biliary tract
through the biliary support tube reveals intrahepatic bile duct stones
remaining
Fig. 12.105 Targeted hard endoscopic lithotripsy and stone removal
through the sinus duct guided by 3D visualization
according to the individual condition of the patient
(Resource 12.5) (Figs.12.111 and 12.112).
12.10.6.5 Attention
• The specic technical operation precautions for choledochoscopy (soft or hard mirror) targeting gravel and
stone removal are the same as for the above-mentioned
method.
• The procedure is most suitable for puncture under the
guidance of B-ultrasound. The best puncture point is in
the anterior approach and the inferior right ribbed area of
the process. Except for the right hepatolithiasis, especially near the right rib and the right posterior rib, it is not
appropriate to use the lateral and posterior puncture
approach.
• The puncture direction of the operation requires an acute
angle (parallel state) with the target bile duct and facing
the hepatic hilus, which is benecial to the operation of
the choledochoscope, so that it can be carried out in a
relatively smooth duct and facilitates the treatment of
stones and biliary stenosis.
298
Severe right hepatic duct stenosis
Section of left hepatict
Right hepatic duct
Fig. 12.106 3D visualization
shows the relationship
between dilated bile duct and
intrahepatic vessels
Fig. 12.107 3D visualization
shows mild left hepatic duct
stenosis, severe right hepatic
duct stricture, right anterior
bile duct stricture, and right
posterior bile duct stricture
Q. Lu et al.
duct
Fig. 12.108 Remove liver tissue of segments II and III, remove stones
through liver cross section, and protect liver tissue of segment IV
Fig. 12.109 Plastic surgery for right hepatic duct stricture, right anterior bile duct stricture, and right posterior bile duct stricture
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.110 3D visualization technology guided open segmental hepatectomy combined with choledochoscopic hard targeting lithotomy for
intraoperative stone removal
Fig. 12.112 Percutaneous
transhepatic
choledocholithotripsy guided
by 3D visualization
299
Fig. 12.111 Target bile ducts were subjected to percutaneous hepatic
puncture under ultrasonic localization
300
Q. Lu et al.
• In the course of stula dilatation, it must be guided along
the guidewire into the biliary tract under the supervision
of X-ray uoroscopy.
• After expanding the sinus to 16 Fr or 18 Fr, the sheath
tube was placed to form the stula wall, avoiding the
hepatic injury and hemorrhage in the further operation,
and facilitating the entry and exit of the rigid
choledochoscope.
12.10.6.6 Signicance
3D visualization technology can optimize the time of establishing a surgical channel of percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL), which is shorter than
the previous channel establishment time: the previous PTCS
lithotripsy method of sinus dilatation is 2–3 weeks, with
more frequent dilatation and a greater likelihood of complications such as bleeding, biliary leakage, biliary tract infection, and peritonitis. Under the guidance of 3D visualization,
the rst stage lithotripsy can be performed directly through
the dilated stula of the liver, and the second stage lithotripsy
can be performed by combined rigid endoscopy one week
after percutaneous hepatobiliary stula. The 3D simulation
visualization surgical system was used to nd the best angle
of the dilated bile duct from the hepatolithiasis as the puncture point. The generally preferred puncture point was on the
right margin of the xiphoid wall, and the dilated left outer
bile ducts B2, B3a, and B3b were selected, or in the middle
line of the right sternal clavicle, and the dilated right bile
duct B7a and B6c as the puncture site. The blood vessels,
intestines, and thorax were avoided, and the target bile duct
was punctured. The sinus was dilated in the rst stage to
carry out gravel and stone removal, which guided the clinical
stages I and II operation successfully. The period of stone
extraction, the distance of stone extraction, and the time of
operation were shortened, and the times of dilation and intraoperative bleeding were reduced, which truly achieves minimally invasive treatment of hepatolithiasis. The main
difculty of operation lies in the uncertainty of the target bile
duct and the variation of the location of the bile duct and
blood vessel. It is difcult to understand the lesion thoroughly by traditional examination methods. The adaptive
region growing algorithm of MI-3DVS software, is applied
to precisely cut the biliary tract system. After 3D reconstruction, the tree structure of the biliary tract system can be displayed as a whole, and the spatial relationship between the
biliary duct and the blood vessels can be accurately displayed. It can guide the actual PTCSL operation to avoid the
major vessels of the hepatic vein, portal vein, abdominal cavity, and thoracic organs, and select the precise puncture site
of the bile duct, which is of great signicance to improve the
success rate of puncture.
Applying 3D visualization technology to guide the com-
bined use of rigid choledochoscope and protective sheath:
the stone and its surrounding structure could be reproduced
by using the 3D visualization technique, and the rst,
second, third, and even fourth-grade branches of intrahepatic bile duct that formed a complete stereoscopic “bile
duct tree” could be observed; the location diagnosis of hepatolithiasis was carried out accurately; different parts and
angles were selected to simulate the lithotripsy with rigid
choledochoscope, and the effect of the simulated operation
was observed repeatedly, according to the distribution of
stones and concrete situation of bile duct dilation. An individualized surgical plan for rigid choledochoscope and
sheath tube was proposed: the dilated sinus had a built-in
supporting sheath, and the operation was performed in the
sheath and the dilated bile duct. During the operation, the
sheath tube was tightly covered in the bile duct with stones,
and the sheath tube “straightened” the bile duct relative to it;
forming a direct passage invitro; the stone was ushed after
crushing. Then the rigid choledochoscope was used for the
“sucking” operation, and the stone owed out quickly
through the sheath tube, which improved the efciency of
stone removal.
3D visualization technique was used to guide the management of biliary stricture: The relationship between the blood
vessel and bile duct must be clearly dened before plasty for
biliary stricture. It was reported that the stone clearance rate,
complication rate and cumulative stone recurrence of hepatolithiasis using PTCSL turned to be approximately 80.0% to
83.3%, 18%, and 32.6% to 40.0%, respectively (Jan and
Chen 1995; Lee etal. 2001; Yeh etal. 1995). The main factor
affecting the treatment effect was severe bile duct stenosis.
In the FreeForm Modeling System virtual surgery environment, the location of bile duct stenosis and the relationship
between the bile duct and its surrounding portal vein and
hepatic vein can be displayed by magnifying, reducing,
rotating, and transparent operation of the 3D model and its
accessories. In the actual operation, the rigid choledochoscopy was applied. The bile duct dilated from the distal end of
the percutaneous liver reaches the stenotic bile duct. Most of
the bile duct stenosis segments are not long; mostly, membranous stenosis, and can be opened by stone forceps. If the
stenosis is obvious, a biliary balloon catheter is used to dilate
it rst, and a series of dilators are successively delivered
along the guidewire for progressive expansion. For those
with a solid scar, an electric knife or laser incision can be
used to dilate the scar with an airbag. After dilation, a support catheter is placed to avoid injury of bile duct blood vessels and reduce complications of biliary tract bleeding. The
above treatment may signicantly reduce the residual rate of
stone, the nal residual rate of stone, and the recurrence rate
of cholangitis. In conclusion, PTCSL, based on the 3D
reconstruction technique, provides a new technique for
patients who cannot tolerate open surgery and postoperative
residual stones.
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
301
12.10.7 Laparoscopic Hepatectomy
Combined withCholedochoscopy
(Soft/Hard) forTargeted Lithotripsy
andStone Extraction Guided by 3D
Visualization
12.10.7.1 Indications
• No history of abdominal surgery, no or mild stenosis of
the hilar bile duct, and no need for bile duct plastic
surgery.
• Stones diffused in the left and right intrahepatic bile ducts
or localized in the left or right intrahepatic bile ducts.
• Patients with hepatic area or segmental atrophy consistent
with the criteria of hepatectomy and if the hospital has the
facilities for laparoscopic hepatectomy or segmental
resection; laparoscopic hepatectomy, or segmental combined with choledochoscopy (soft/hard) targeted lithotripsy, or stone extraction guided by 3D visualization, can
be performed.
12.10.7.2 Contraindications
• Patients with obvious bleeding and coagulation
dysfunction.
• Liver function Child-Pugh class C.
• Inability to tolerate general anesthesia or pneumoperito-
neum.
12.10.7.3 Surgical procedures
General anesthesia with tracheal intubation.
• Routine establishment of pneumoperitoneum, the estab-
lishment of puncture holes, and placement of puncture
sheath.
• Abdominal cavity exploration, laparoscopic cholecystec-
tomy, and common bile duct exploration.
• According to the preoperative individualized 3D visual-
ization model of patients, the rst hepatic portal is dissected, the corresponding hepatic segment/region
blocked, or the Pringle technique used to temporarily
block the left or right hepatic blood ow; and the damaged liver segment and the stricture segment of the intrahepatic bile duct removed as much as possible.
• According to the thickness of the common bile duct, the
appropriate dilator and sheath tube are selected and xed
by an assistant. The dilator is inserted through the subxiphoid puncture hole.
• A water pump with adjustable pressure (0.9% sodium
chloride solution) is connected with a hard mirror and
reaches the target bile duct under the guidance of the 3D
model.
• Pneumatic ballistic lithotripsy: A ballistic lithotripsy
device is installed under the guidance of a hard mirror.
Stones larger than 10mm are crushed by pneumatic ballistic lithotripsy. The ballistic pressure is automatically
maintained within the range of 0.2–0.4 MPa by the
pump.
• Stone extraction through net basket: The crushed stones
are repeatedly extracted by a net basket. Floating gravel is
washed out through the sheath tube under the impulse of
water. Bile ducts of Grade IV and above or with small
bifurcation angles were removed with Cook net basket or
“suction” of water ow.
• Under the protection of the crushed stone casing and the
rigid mirror light source, the rigid mirror can enter and
exit the left and right liver smoothly, dilating the bile duct
with the aid of the rigid mirror “pick,” “pull,” and “pry”
forces. Under the guidance of a 3D visualization model or
3D printing model, the intrahepatic bile duct stones can
be accurately located, and lithotripsy and stone extraction
can be carried out.
• The strictured intrahepatic duct is dilated with a soft dilator, such as a biliary balloon. For the strictured duct with
a solid scar the bile duct should be opened with an electric
knife rst, and then a stent should be placed immediately
after dilatation. Its distal end should exceed the strictured
segment.
• Finally, perform exploration for, and remove extrahepatic
bile duct stones are, and observe the function of the Oddi
sphincter. The duodenal cavity can be accessed by
choledochoscope.
• T-tube and drainage tubes should be retained for direct
cholangiography and trans-sinusoidal treatment of calculi
after operation.
12.10.7.4 Attention
• The specic operation of choledochoscopy (soft/ hard)
targeted lithotripsy is the same as that of the open hepatectomy or segment section combined with choledochoscope (soft/hard) targeted lithotripsy guided by 3D
visualization.
• If the bleeding is difcult to control or the patient cannot
tolerate pneumoperitoneum during total laparoscopic
hepatectomy, immediate reversion to laparotomy is
necessary.
• Before rigid mirror lithotripsy, a small sliver should be
used to ll the lower end of the common bile duct to prevent ushing water or ne stones from entering the intestine; small gauze should be laid on the left and right
omentum holes, and the suction tube should be placed for
continuous suction to prevent ushing water and ne
302
Q. Lu et al.
stones from owing into the abdominal cavity, and postoperative abdominal cavity infection. The gauze and
sliver are removed at the end of the operation.
• For patients with diffuse cholelithiasis in the left and right
intrahepatic bile ducts, stones can be removed by stages
in order to avoid water intoxication (Resources 12.6 and
12.7) (Figs.12.113, 12.114, and 12.115).
Fig. 12.113 The upper right image shows a 3D subabdominal biliary
rigid lens through cannula into the common bile duct and intrahepatic
bile duct for lithotripsy; the lower left image shows the biliary tract with
biliary rigid lens for lithotripsy
12.10.8 Treatment ofHepatolithiasis
Complicated withBiliary Cirrhosis
Guided by 3D Visualization
In patients with hepatolithiasis, chronic recurrent cholangitis
and mechanical obstruction resulted in thickening of the
brous tissue, inltration of inammatory cells, and formation of brous separation in the portal vein. The new liver
tissue nodules compress the hepatic venous branch, which
causes the portal vein to shrink, becoming irregular, and
thickened. It reduces portal venous blood ow, leading to
liver atrophy and portal hypertension. At the same time, the
complicated hepatolithiasis causes atrophy of the liver lobe
or segment of the liver; resulting in the displacement of the
hepatic portal and the distortion of the portal vein, which
affects the portal venous blood ow. Extensive stenosis,
infection, and cholestasis of hepatobiliary duct cause hepatocytes to be damaged and regenerate, which easily leads to
biliary cirrhosis and portal hypertension. These progressive
pathological changes worsen over time. With early detection,
pathological changes of the liver can be halted if the obstruction and stones are removed.
Is the choice of surgical methods for this type of patient
rst to resolve portal hypertension, or to treat biliary obstruction? Is it a simultaneous operation or a staged surgical treatment? Is it an open surgery, a liver transplant, or a minimally
invasive treatment? Scholars have their own opinions. At
present, hepatolithiasis complicated with biliary cirrhosis
Fig. 12.114 Biliary rigid
lens for lithotripsy under 3D
laparoscopy
display
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
bile duct
T-tube
a
bile duct
display
T-tube
b
Fig. 12.115 No calculi observed on postoperative direct cholangiography. (a) 2013-12-11; (b) 2014-01-22
often need multiple surgical methods, but the operation is
difcult and risky. Therefore, individualized design of the
surgical scheme for cholelithiasis should be carried out
according to the preoperative Child-Pugh classication of
liver function, the experience of the operator, equipment
condition, and 3D visualization results. Thus, choose one or
more of the above surgical methods or liver transplantation
for treatment.
12.10.8.1 Preoperative Evaluation
3D visualization is used to evaluate the changes of the portal
vein system and collateral circulation, the distribution of
stones in the hepatobiliary duct, the degree and extent of
bile duct stricture, the pathological features of the liver, and
the reserve liver function. It has important value in determining the choice of treatment, operative method, and operative approach. This is the unique advantage of 3D
visualization.
12.10.8.2 Preoperative Preparation
• Liver function reserve A grade.
• Acquisition of high-quality CT image data, especially in
the portal vein phase.
• 3D visualization evaluation.
303
12.10.8.3 Contraindications
• Obvious bleeding and coagulation dysfunction.
• Liver function Child-Pugh class C.
• Inability to tolerate general anesthesia.
12.10.8.4 Operation Methods
In the case of patients with a bile duct drainage tube or
support tube, the target lithotripsy through sinus choledo-
choscope (soft or hard endoscope) guided by 3D visualization should be adopted.
For those without a bile duct drainage tube or sup-
port tube, open hepatectomy or segmentectomy combined
with choledochoscopy (soft/hard mirror) targeted lithotripsy
and stone removal guided by 3D visualization should be
adopted.
• If the surgical approach is severely impeded due to history of multiple biliary tract operations, portal hypertension, severe hepatic adhesions, and extensive portal vein
branch expansion, it is necessary to fully understand the
operation method of the previous one to avoid the dilated
portal vein branch and carefully search for the bile duct
along the right liver surface. Once the bile duct is conrmed, the operation is assured of success.
• Prevent bleeding from varicose veins on the surface of the
bile duct wall and intima due to the thickening of the bile
duct wall.
• Choledochoscopy (soft/hard): If suppurative bile is found,
stones blocking the hilar of the liver are removed as much
as possible, and T-tube is placed. After antimicrobial chemotherapy, targeted lithotripsy through sinus choledochoscope (soft or hard) guided by a 3D visualization technique
is selected.
• Select the appropriate and sheath, according to the thickness of the bile duct. Dilator-specic methods are the
same as that for the targeted lithotripsy through sinus choledochoscope guided by 3D visualization.
• Finally, the extrahepatic bile duct stones are located and
removed, the distal bile duct is observed to be unobstructed and the Oddi sphincter normal. T-tubes and
drainage tubes are indwelled.
12.10.8.5 Attention
• This case is exceptional. Biliary cirrhosis usually occurs
after multiple biliary surgeries, which requires a combination of various surgical methods. Moreover, it is necessary to design an individualized surgical program for
biliary calculi because the operation is difcult and
hazardous.
304
The biliary ducts and
The porta
vein system
d
d
Q. Lu et al.
• Most importantly, bleeding, even massive hemorrhage
may occur due to inammation, hyperemia, edema, erosion, blood leakage, and vascular varices of the bile duct.
Therefore, the hard mirror cannula should be guided by
the light source of the hard choledochoscope throughout
the process to prevent the blind entry of punctured variceal vessels. The hard mirror must be placed in the mid-
Fig. 12.116 3D visualization
shows hepatic atrophy and
hypertrophy; digital type:
L
, S
, D
II- VII
undened
II-VII
, C
dle of stone in the eld of view during lithotripsy to
prevent sharp lens oblique surface injury or puncture of
blood vessels, bile duct, bleeding and bile leakage, and
avoid the metal mesh head stimulating the erosive bile
duct intima (Resources 12.8, 12.9, and 12.10)
(Figs. 12.116, 12.117, 12.118, 12.119, 12.120, 12.121,
12.122, 12.123, 12.124).
The dilated biliary ducts an
calculus
The liver
Fig. 12.117 3D visualization
shows strange forms of the
intrahepatic vessels and bile
ducts, and the bile ducts are
lled with stones
Fig. 12.118 3D visualization
shows the dilated and tortuous
portal vein system
The liver
The
pancreas
dilated biliary ducts an
calculus
l
The spleen
The hepatic
artery
calculus
The portal vein
system
The hepatic artery
Dilated bile duct
Dilated portal vein
The bile duct
12 Digital Surgical Diagnosis andManagement ofHepatolithiasis
Fig. 12.119 3D visualization
shows liver atrophy and
Hepatic vein
hypertrophy, with strange
forms of intrahepatic vessels
and bile ducts, and bile ducts
lled with stones
Portal vein
Fig. 12.120 3D visualization
shows the dilated and tortuous
portal vein system
305
The spleen
The pancreas
The kidney
Fig. 12.121 3D visualization
shows the relationship
between the hepatic artery
and bile duct
The hepatic artery
306
e
Fig. 12.122 Ballistic lithotripsy
Q. Lu et al.
12.10.9 Complication Prevention
andManagement ofTargeted
Lithotripsy forHepatolithiasis
with3D Visualization Assisted by 3D
Laparoscopy andCholedochoscopy
3D visualization can be used to evaluate the lesions of bile
duct and stones in all directions and from different angles;
and assist in intraoperative navigation to reduce the blindness of intraoperative exploration; 3D laparoscopy is clear,
stereoscopic, and effective; the hard lens of the
choledochoscope has magnication effect, clear eld of
vision and large operating cavity, and when it is combined
with the individualized 3D reconstruction model, the location of stones can be quickly identied and the operation
time can be shortened. The combination of these three technologies can remove stones quickly, accurately, safely, and
thoroughly. Nonetheless, a certain risk of complications in
this procedure still exists due to the complexity of hepatolithiasis and the characteristics of various diseases, especially
in the early stages of this technique.
Fig. 12.123 Calculus taken out of the intrahepatic bile duct
intrahepatic bil
duct
Fig. 12.124 No residual calculi were found by direct postoperative
cholangiography
12.10.9.1 Biliary Injury
Causes
Most injuries are caused by a blind and violent rigid mirror
exploration or lithotripsy. In less severe cases, local damage
of bile duct mucosa is caused, while in severe cases penetrating injury of the bile duct results, even combined with an
injury of adjacent organs. Especially, the diseased bile duct
is located in segment VII of the liver, adjacent to the diaphragm, and there is long-term inammatory stimulation
resulting in adhesion between the liver and the diaphragm.
Or if during the operation, the lithotripsy rod accidentally
pierced the bile duct and reached the liver capsule and diaphragm, which formed the communication among the bile
duct, diaphragm, and thoracic cavity.
Preventive Measures
• When it is difcult to nd the branch of the intrahepatic
grade II bile duct during the operation, we can combine
3D visual targeting to locate the bile duct and stones, so as
to avoid blind exploration.
• The operation path of bile duct communicating with the
outside, should be established by using the middle diameter sheath tube, in order to ensure the operation of the
choledochoscope in the sheath tube.
• For patients without choledocholithiasis, choledocholi-
thotomy should be performed at a high level to avoid bile
duct laceration during choledochoscopy.