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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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15 Digital Surgical Diagnosis andTreatment ofGallbladder Cancer
347
c
Fig. 15.5 (continued)
3D Visualization ofTumor andPortal Vein System
Due to the variety of portal vein variations and the frequent
morphological, structural, and pathological changes of the
hepatic hilar in gallbladder carcinoma, it is highly relevant
when dening the variation of portal vein course and conuence pattern preoperatively to avoid damage to the abnormal
conuence of portal vein branches, and to guide portal vein
resection and reconstruction (Figs.15.7 and 15.8).
3D Visualization ofTumor andBiliary System
To determine the variation of biliary tract system and to
guide the choice of surgical methods for bile duct reconstruction (Figs.15.9 and 15.10).
3D Visualization ofVirtual Surgery
The residual liver volume was calculated to evaluate the
safety of operation. As shown in Fig. 15.11, the lesion is
located at the fundus and neck of the gallbladder, breaking
through the serosa layer and is considered as gallbladder
cancer (T3N0M0). For extended right hepatectomy: the volume of extended right hepatectomy is 754cm3, accounting
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Fig. 15.6 Adjacent relationship between tumor and hepatic arterial system. (a) Anterior view; (b) posterior view; (c) image fusion
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Y. Liu et al.
a
b
c
Fig. 15.7 CT images of portal vein system (portal venous phase)
for 75.2% of the total liver volume, while the remaining
residual liver volume is 249cm3, accounting for 24.8% of the
total liver volume. For extended left hepatectomy, the volume of extended left hepatectomy is 537cm3, accounting for
53.5% of the total liver volume, while the remaining residual
liver volume is 467cm3, accounting for 46.5% of the total
liver volume. For S4b+S5 segmentectomy: the volume of
liver segments S4b+S5 is 116cm3, accounting for 11.6% of
the total liver volume, while the remaining residual liver volume is 887cm3, accounting for 88.4% of the total liver volume. Above all, the liver S4b+S5 segmentectomy should be
selected.
15.3.4 Value of3D Visualization
intheDiagnosis andTreatment
ofGallbladder Cancer
The ultimate goal of applying a three-dimensional visualization system is to guide precise hepatobiliary surgery. Its
greatest advantage is visualization and repeatability. After
fully analyzing the distribution, course, variation of the complex hepatic duct system and their adjacent relationship to
the tumor, the relationship of hepatic vessels (portal vein,
hepatic vein, inferior vena cava) to bile duct was evaluated.
With the system’s multiple display functions such as arbi-
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15 Digital Surgical Diagnosis andTreatment ofGallbladder Cancer
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349
Fig. 15.8 Adjacent relationship between tumor and portal vein system. (a) Anterior view; (b) Lateral view; (c) Image fusion
Fig. 15.9 Imaging of biliary system. (a) CT image; (b) MRCP image; (c) PTCD image
350
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Y. Liu et al.
c
Fig. 15.9 (continued)
c
Fig. 15.10 Adjacent relationship between tumor and biliary system. (a) Anterior view; (b) Posterior view; (c) Image fusion
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15 Digital Surgical Diagnosis andTreatment ofGallbladder Cancer
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351
Fig. 15.11 Image of virtual surgical resection. (a) Extended right hepatectomy; (b) extended left hepatectomy; (c) Liver resection of S4b+5
trary movement, rotation, zooming, simulated segmentation;
simulated surgery is performed. The spatial relationship
between the intrahepatic vascular tree and bile duct tree can
be accurately mastered before an operation, to predict the
complicated and dangerous conditions that might occur in
the actual operation. When the cut layer involves important
blood vessels or bile ducts in the liver with a risk of injury,
modications can be made accordingly. After simulating different surgical plans and comparing the advantages and disadvantages of various programs, a reasonable individualized
surgical plan can be formulated, and necessary preventive
measures taken in advance. Through the modication and
optimization of the surgical path, the incidence of intra- and
postoperative complications can be minimized, and the success rate of the operation can be improved.
15.4 Application of3D Visualization
Technology inCombined
Hepatectomy
andPancreaticoduodenectomy
15.4.1 Surgical Indications
15.4.1.1 Indication forCombined Hepatectomy
Currently, the surgical procedure for gallbladder cancer is
mainly based on the Nevin staging and T stage of TNM stag-
ing issued jointly by the American Joint Cancer Commission
(AJCC) and the International Union against Cancer (UICC).
Because there is no serosa on the liver surface of the gallbladder, the T1b stage gallbladder carcinoma located at this
site may cause micrometastasis of the liver bed, but the distance is less than 16mm; therefore, for gallbladder cancer
located at stage T1b, wedge resection of the liver is recommended at a distance of more than 2cm from the gallbladder
bed. In the T2 phase, the gallbladder cancer cells ow into
the liver through the gallbladder vein gyrus to an average
distance of 2–5cm from the gallbladder bed, and at least one
direction range is more than 4cm, so at least cholecystectomy with the S4b S5 segment of the liver should be performed. For the T3 phase, the tumor has invaded broke
through the serous layer and/or directly invaded the liver,
and/or invaded an adjacent organ or tissue structure outside
the liver. Therefore, conventional extended lymph node dissection is recommended. For patients with T3N0 stage, cholecystectomy combined with hepatic S4b S5 resection plus
extended lymph node dissection was required; for patients
with T3N1 stage, it is suggested that cancer cells transferred
to the entire right half liver along the lymphatic system or
Glisson system should be treated with extended lymph node
dissection. The tumor of stage T4 gallbladder cancer invades
the main portal vein or hepatic artery, or more than 2 extrahepatic organs or tissues, so it is possible to achieve R0
resection in patients with stage T4N0M0 and T4N1M0 gall-
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Y. Liu et al.
bladder cancer by combined extended radical resection of
involved organs.
15.4.1.2 Indications forCombined
Pancreaticoduodenectomy
Whether combined pancreaticoduodenectomy is required
mainly involves three conditions: abdominal para-aortic
lymph node metastasis, invasion of the middle and lower
common bile duct, and direct invasion of the head of the pancreas. Of the three, the relationship between lymph node
metastasis and HPD should be particularly cautious.
Gallbladder cancer is very prone to lymph node metastasis.
Numerous studies have found that once gallbladder cancer
invades the muscularis, lymph node metastasis occurs in
25%~62% of cases (Fong etal. 2000). Generally speaking,
lymph node metastasis is most likely to occur in the hepatoduodenal ligament (pN1), but there are not a few cases of
lymph node (pN2) metastasis before and after pancreatic
head, up to 8%~14% (Tsukada etal. 1996). In a report of 5
cases of gallbladder cancer with initial symptoms of obstructive jaundice, the authors from Johns Hopkins University
concluded that in some cases, gallbladder cancer had metastasized to the anterior and posterior pancreatic head and even
para-aortic lymph nodes with limited hepatic inltration
(Doty etal. 2002). Although pN2 lymphatic metastasis is a
sign of poor prognosis, some scholars have performed extensive radical surgery and achieved good results. For example,
Sasaki etal. (2004) obtained a satisfactory 5-year survival
rate after liver S4b + S5 resection, pancreaticoduodenectomy, and enlarged regional lymph node dissection in such
patients. Lymph node metastasis of abdominal aorta was
classied into the M1 stage, which was previously considered as a contraindication for a radical mastectomy of gallbladder carcinoma. However, in recent years, Nishio etal.
(2007) reviewed and analyzed the patients who underwent
radical resection of single-center 166IV gallbladder carcinoma. It is pointed out that patients with paraventricular
lymph node metastasis and other M1 stage patients may benet from HPD operation, and the prognosis is signicantly
better than that of patients who give up the operation.
Therefore, it is suggested that HPD should be performed in
patients with para-aortic lymph node metastasis. Combined
with literature reports and clinical experience, the author
believes that for patients with locally advanced gallbladder
cancer, HPD surgery can be considered in the following
cases: the tumor is already in the advanced stage, but if the
location is limited, it can be separated from the surrounding
tissues; the tumor invaded the liver, lower common bile duct,
pancreas, and duodenum; the retropancreatic lymph node
metastasis; for those with para-aortic lymph node metastasis,
HPD may be considered even without direct pancreatic head
or duodenal inltration.
15.4.2 Preoperative Preparation
15.4.2.1 Assessment ofLiver Function Reserve
The conditions of radical resection of gallbladder cancer
include:
• The lesions of gallbladder and its adjacent organs and
regional metastatic lymph nodes can be removed.
• The residual liver function can be compensated, and the
integrity of its vascular structure can be preserved or
reconstructed.
• The patient can tolerate the surgical trauma.
As mentioned above, the range of hepatectomy for gall-
bladder cancer patients is based on stage T of the TNM staging published jointly by the AJCC and The Union for
International Cancer Control (UICC). Hepatectomy is an
essential treatment for hepatobiliary diseases. Due to hepatobiliary diseases complicated with liver parenchyma damage,
liver function reserve is reduced to varying degrees, and liver
insufciency after hepatectomy has become an important
cause of perioperative death of patients. Accurate preoperative assessment of liver reserve function is of great signicance for the selection of reasonable treatment methods, the
safe range of hepatectomy, and the reduction of the incidence
of postoperative liver failure.
There are many methods to evaluate liver reserve func-
tion. The main methods can be divided into ve categories:
• Liver serum biochemical test.
• Comprehensive scoring system.
• Quantitative liver function test.
• Imaging evaluation of hepatic parenchyma and vascular
lesions.
• Liver volume measurement.
A comprehensive assessment should be made according
to the patient’s general condition, the function of the liver,
and other vital organs as well as tumor stages. The staging
of gallbladder cancer was evaluated according to the results
of MSCT and MRI.For patients requiring large-scale hepatectomy, the liver function reserve and liver volume should
be quantitatively evaluated before surgery, so as to determine the patients’ required functional liver volume and safe
liver resection volume. It is generally considered that
healthy liver can tolerate hepatectomy with 75% ~ 80%
parenchyma resection or hepatectomy with 20%~25% of
residual liver functional volume. The future liver volume
(FLR) of patients with jaundice should be more than 40%.
Specic criteria can be referred to as the Expert Consensus
on Assessment of Liver Reserve Function before
Hepatectomy (2011 edition).
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15 Digital Surgical Diagnosis andTreatment ofGallbladder Cancer
353
15.4.2.2 Assessment ofImaging Examination
Radical surgery should ensure that the margin reaches R0
resection without invasion of tumor cells. The prognosis of
gallbladder cancer patients is closely related to radical
resection. Preoperative clinical and imaging data of gallbladder cancer patients should be fully collected to evaluate
whether radical resection is feasible. Imaging examinations,
including B-ultrasound, endoscopic ultrasonography,
enhanced abdominal CT (Fig.15.12), and MRI, are helpful
for the diagnosis and staging of gallbladder cancer. Positron
emission tomography (PET) can detect potential occult
metastases. Laparoscopy can rule out the possibility of small
peritoneal implantation metastasis of gallbladder carcinoma
before the operation.
15.4.2.3 Preoperative 3D Visualization Evaluation
3D visualization based on CT or MRI is becoming more
and more mature and plays a key role in the preoperative
evaluation of gallbladder cancer. Two-dimensional data
were obtained by 64-slice spiral CT plain scan of the upper
abdomen and phase iii enhanced scan before the operation
and stored in DICOM format. The three-dimensional
reconstruction of the data was carried out by MI-3DVS.The
local anatomical relationship and vascular variation were
carefully observed from multiple perspectives with the
application of transparent visualization technology. The
location of the gallbladder tumor and its three-dimensional
adjacent relationship with surrounding tissues and vessels
were determined, and the resectability of the tumor was
evaluated in detail. We applied 3D visualization technology in radical cholecystectomy, with the aim of: making
the preoperative evaluation more accurate, helping to make
the resectable judgment and guide the rational choice of
surgical approach, and to safely and effectively complete
radical cholecystectomy, improving the R0 resection rate
of tumor in a real sense, and improving the prognosis of
patients. By magnifying, narrowing, rotating, and transparent processing of reconstructed images, the anatomical
location and relationship of gallbladder tumors, livers, and
major peripheral blood vessels (such as the celiac trunk,
superior mesenteric artery, portal vein, and superior mes-
Fig. 15.12 (a-d) CT images of gallbladder cancer
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Y. Liu et al.
enteric vein, common bile duct and adjacent organs such
as the stomach, duodenum, and transverse colon) can be
clearly displayed; so as to guide the preoperative resectability assessment (Fig.15.13). Compared with traditional
two-dimensional images, 3D visualization can not only
reproduce the size, location, and distribution or variation
of surrounding blood vessels of the gallbladder, but also
rotate it at any angle and zoom into important parts at will.
The dynamic observation of the 3D gallbladder space-
occupying lesion and its adjacent relationships can not
only guarantee the safety of operation but also help doctors to locate the lesion before operation accurately, guide
doctors to choose the appropriate surgical approach and
evaluate the curative effect and risk. At the same time, preoperative simulated surgery can be carried out. During the
operation, effective preventive measures can be taken to
control intraoperative bleeding, shorten the operation time,
and minimize the trauma to the body.
Fig. 15.13 (a-f) 3D reconstructed images of gallbladder cancer
15 Digital Surgical Diagnosis andTreatment ofGallbladder Cancer
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355
Fig. 15.13 (continued)
15.4.3 Surgical Procedures
15.4.3.1 Resection Range
Range ofLiver Resection
For liver-bed gallbladder carcinoma in stage T1b, it is recommended to perform wedge-shaped resection with a row
spacing of >2 cm from the gallbladder bed. For stage T2,
cholecystectomy with hepatic S4b+S5 should be performed
at least. For patients with stage T3N0, cholecystectomy combined with hepatic S4b+S5 resection plus extended lymph
node dissection should be performed. For patients with stage
T3N1, it is suggested that cancer cells metastasized to the
whole right liver along with the lymphatic system or Glisson
system, requiring right hepatic resection or right trisectionectomy plus expanded lymph node dissection. Gallbladder
cancer tumor in stage T4 invades the main portal vein or
hepatic artery, or more than two extrahepatic organs or tissue
structures. For patients with stage T4N0MO and T4N1M0
gallbladder cancer, extended radical resection combined
with resection of involved organs may still achieve R0
resection.
Radical Pancreaticoduodenectomy
The pancreas is severed at the left margin of the portal vein–
superior mesenteric vein junction and the head of the pancreas, including the uncinate process of the pancreas, is
completely resected. At the conuence of the gallbladder
duct, the common hepatic duct is transected, and the extrahepatic bile duct, distal stomach, duodenum, and proximal part
of the jejunum are resected below the hepatic hilum. Gerota
fascia is removed along with the pancreatic head, and lymph
nodes and plexus in the region are removed.
15.4.3.2 Surgical Steps (A Case ofGallbladder
Cancer Invading Duodenum)
• Step 1 Laparoscopic or laparotomy exploration. Specic
surgical methods were determined according to the results
of preoperative imaging, 3D visualization, and intraoperative exploration. Radical resection was determined, generally taking a right upper abdominal reverse “L” incision
into the abdomen. The tumor was located in the base of
the gallbladder, with about 6cm diameter and invading
the duodenum (Fig.15.14).
• Step 2 Expanding Kocher’s incision. Kocher technique
was used to explore the posterior pancreatic head; the
Peng’s Multifunction Operative Dissector (PMOD) technique was used to incise the duodenal peritoneum
(Fig.15.15). The left anterior transverse mesocolon was
incised. The descending part of the duodenum, the horizontal part, and the head of the pancreas were freed from
the retroperitoneal to the left side of the abdominal aorta.
The right side of the root of the superior mesenteric artery
was exposed above the level of the left abdominal aorta
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Y. Liu et al.
Fig. 15.14 Gallbladder carcinoma involving the duodenum
Fig. 15.15 Kocher incision
Fig. 15.17 Lymph nodes between inferior vena cava and abdominal
aorta were dissected
Fig. 15.18 Dissecting the distal stomach
Fig. 15.16 Revealing the left renal vein
and left renal vein. The inferior vena cava and adipose
lymphoid tissue around abdominal aorta were removed
(Figs.15.15, 15.16, and 15.17).
• Step 3 The right gastrocolic ligament was severed. The
greater omentum was opened at the upper edge of the
transverse colon, the greater omentum, and the right half
of the anterior transverse mesocolic lobe were resected,
the right side of the middle colon artery was severed and
ligated at the root of the right gastrocolic vein. At the
same time, the lymph nodes of group 14V were dissected.
The fth group of lymph nodes on the upper edge of the
Fig. 15.19 Hepatoduodenal ligament dissection
right gastric artery was dissected, and the body of the
stomach was severed. About 40% of the distal stomach
was resected (Fig.15.18).
• Step 4 The lymphatic adipose tissue around the common
hepatic artery was dissociated from the root of the left
gastric artery along the right side of the common hepatic
artery. The hepatoduodenal ligament was dissected with
PMOD, and skeletal dissection was carried out
(Fig.15.19).