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16 Digital Diagnosis andManagement ofCholangiocarcinoma
417
i
j
Fig. 16.60 (continued)
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Application of3D Visualization
Technology inPerihilar Surgery
JianWang, JiayanYan, andChihuaFang
17
17.1 Introduction
The Perihilar area is a complex region where bile ducts, portal veins, hepatic arteries, lymphatics, and nerves intertwine
often in an unpredictable way. Anatomical variation is common and the spatial relationships between the vessels are difcult to predict. Imaging techniques greatly assist the
surgeon in visualizing the individual anatomy, improving
operative precision, patient safety, and shortening duration
of surgery. This chapter outlines the characteristic anatomical variation and spatial relationships between the portal
veins, hepatic arteries, and bile duct. It categorizes: perihilar
diseases and discusses their impact on the hilum, atrophy,
and hypertrophy of the liver lobes. We discuss the nature of
invasive disease and concomitant difculties during surgery.
We also outline the treatment of disease, and the value of
imaging technologies, modeling hepatic lobe segmentation
and related vasculature to enable simulated surgery, and for
precise preoperative and intraoperative guidance. The chapter closes with a description of the 3D imaging software systems, from image acquisition, and data migration to 3D
modelling of the perihilar region and the liver.
17.2 Categories ofPerihilar Diseases
17.2.1 Anatomical Position
ofthePerihilarArea
The rst hilus is the transverse part of the “H”-shaped groove
on the undersurface of the liver, through which bile ducts,
hepatic arteries, portal veins, lymphatics, and nerves enter
and exit the liver. The upper and top part of the hilum is the
J. Wang · J. Yan
Renji Hospital, School of Medicine, Shanghai Jiaotong University,
Shanghai, China
C. Fang (
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
*)
quadrate lobe, and the bottom is the caudate lobe. Perihilar
area refers to a narrow anatomic area near the rst hilus that
contains blood vessels, bile ducts, and brous connective tissue surrounding it. The perihilar area is traversed by portal
veins, hepatic artery, and bile ducts that enter the hepatic portal, and the three ductal structures intersect and form an intricate 3D structure, which is the area with the most anatomical
variation and the most complicated anatomy in hepatobiliary
surgery.
17.2.2 Categories ofPerihilar Diseases
Perihilar disease has been dened as disease occurring in or
involving the perihilar area; it involves tumor, inammation,
injury and malformation, and includes perihepatic hilar
tumor, traumatic strictures or inammatory strictures of hilar
bile ducts, hilar incarceration of hepatolithiasis, and central
cystic dilatation of bile ducts (Tirumani etal. 2014).
17.2.2.1 Perihilar Tumor
Perihilar tumors include perihilar biliary tract tumors and
hepatocellular carcinomas invading the hilar. Perihilar biliary tract tumors include hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma invading the hilar, and gallbladder
carcinoma invading the hilar (Wang and Chen 2014).
Although the biological behaviors of the three are not identical, they are collectively called perihilar biliary tract tumors
as these tumors often invade the hepatic portal plate and then
invade the hepatic artery and portal vein, causing similar
clinical presentation such as obstructive jaundice and cholangiocarcinoma, and similar clinical characteristics, such as
difcult radical surgery, low R0 resection rate, high intraoperative bleeding, and high perioperative complications and
mortality.
Centrally located hepatocellular carcinoma (HCC)
involves tumors adjoined to the porta hepatis, mainly located
in Couinaud’s segments I, IV, V, and VIII.By virtue of their
proximity to important intrahepatic vessels, they often invade
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
C. Fang, W. Y. Lau (eds.), Biliary Tract Surgery, https://doi.org/10.1007/978-981-33-6769-2_17
421
422
2cm
2cm
Bismuth IV (R)Bismuth V
J. Wang et al.
the bile ducts and blood vessels in the porta hepatis.
Therefore, the operation is difcult and risky (Wu et al.
1999; Yu etal. 2017; Ali etal. 2015; Lau etal. 2017a, b).
17.2.2.2 High Biliary Stricture
High biliary stricture, also known as hilar biliary stricture,
refers to strictures above the left and right hepatic duct conuence. All of the following conditions can be regarded as
high biliary stricture:
• Bismuth-Corlette classication: type II–V (Fig. 17.1)
(Bismuth and Majno 2001).
• Strasberg classication: types E2–E5 (Strasberg et al.
1995).
• Type II1d stricture, with a stump shorter than 2cm, and
type II 2d–II 4d stricture, according to the classication of biliary stricture in the “Guidelines for the
Diagnosis and Treatment of Biliary Injury (2013 edition)” put forward by the Chinese Medical Association
(Wang 2017a, b).
Hilar biliary strictures are not uncommon. Important eti-
ologies of hilar biliary strictures include iatrogenic (postliver transplantation or post interventional therapy), and
inammatory strictures. The most common cause is a direct
or indirect biliary injury during cholecystectomy, accounting
for more than 90% of biliary stricture (Wang and Wang 2011;
Gluszek etal. 2014). Biliary strictures present a diagnostic
and treatment challenge, and its most effective treatment
modality remains surgery.
17.2.2.3 Cystic Dilatation oftheCentral Bile
Ducts
Central cystic dilatation of bile duct involves cystic dilatation of the bile duct in the hilum, including Todani (Todani
etal. 1977) types IVa and V (Fig. 13.1), and types B and D of
Dong’s classication (Dong etal. 2013a, b).
It is recommended that patients diagnosed with biliary
cystic dilatation should receive surgical treatment as soon as
possible. General principles in the management of biliary
cystic dilatation are resection of the diseased bile duct, management of secondary lesions, and reconstruction of the bilioenteric pathway. Since the residual cystic dilatation of the
bile duct may lead to complications such as recurrent cholangitis, secondary bile duct stones and even bile duct canceration, it is important to resect the cystic dilatated bile duct
(Takeshita etal. 2011; Saluja etal. 2012).
17.2.2.4 Incarceration ofIntrahepatic Duct
Stones intheHepatic Hilum
Hepatolithiasis is usually associated with complications such
as liver atrophy, biliary stricture, portal hypertension, and
hepatic failure. This condition is challenging to manage
because of a high rate of postoperative complications, recurrence, and residual stones (Li etal. 2016; Wang 2016). Its
common pathological changes are hilar biliary stricture and
incarceration of intrahepatic duct stones at the hepatic hilum.
Successful treatment of this disease depends on surgical
management of hilar biliary stricture and removal of the
impacted stones. Stone incarceration can easily lead to
inammatory adhesions in the hepatic hilum, obstruction of
Fig. 17.1 Bismuth-Corlette
classication of the bile duct
strictures (Bismuth and Majno
2001)
2cm 2cm
Bismuth I Bismuth II Bismuth III
2cm 2cm
Bismuth IV (L)
17 Application of3D Visualization Technology inPerihilar Surgery
423
access through the hepatic hilum, and injury of hilar vessels
during operation (Wang 2017a, b).
17.3 Characteristics ofPerihilar Diseases
17.3.1 Anatomical Variation
ofthePerihilarArea
The anatomy of perihilar area has two characteristics: anatomic and spatial conformational variation of hepatic
vascular.
17.3.1.1 Anatomical Variation ofHepatic
Vessels
The perihilar region has a narrow space, and three sets of
vascular structures intersect and form an intricate array of
three-dimensional structure; the course and conuence pattern of the bile duct, hepatic artery, and portal vein vary
greatly between individuals (Wang 2015). It has been
reported that hepatic arterial variation is present in about
1/3rd of individuals with at least ten different types (Michels
1966a, b); portal vein variation is present in about 1/5th of
individuals with four different types (Germain etal. 2014;
Atri etal. 1992); bile duct variation is present in about 1/5th
of individuals, with six different types (Chaib etal. 2014).
Hepatic Arterial Variation
The incidence of hepatic arterial variation is 30%–40%
(Lopez-Andujar et al. 2007; Hiatt et al. 1994). Michel
divided hepatic arterial variation into 10 types (Table 17.1)
(1966).
However, variants and patterns that were not dened in
Michel’s’ classication are frequently encountered during
surgery. Yan etal. (2020a, b) established a new classication
named CRL classication to dene anatomical variations of
hepatic arteries. The CRL classication system was formulated based on nomenclature rules structured according to
parameters concerning the origins of common hepatic artery
(CHA), right hepatic artery (RHA), and left hepatic artery
(LHA). The rules are as follows (Table 17.2 and Fig.17.2)
(Yan etal. 2020a, b).
C_ describes the origin of the CHA.Specically, C alone
indicates that the CHA arises from the coeliac trunk, whereas
the ‘_’ is replaced by letters denoting other origins: C
, CHA
A
arises from aorta; CL, CHA arises from left gastric artery
(LGA); CS, CHA arises from superior mesenteric artery
(SMA); and CO, CHA arises from other arteries.
R, Rr_ and Ra_ describe the origin of the RHA, replaced
RHA (rRHA) and accessory RHA (aRHA) respectively: R
alone, RHA arises from proper hepatic artery (PHA) or
CHA; RrA/RaA, rRHA/aRHA arises from aorta; RrC/RaC,
rRHA/aRHA arises from coeliac trunk; RrG/RaG, rRHA/
Table 17.1 Hepatic arterial variants according to the Michel’s
classication
Type
Type I: Standard anatomy (RHA and LHA from
CHA)
Type II: Replaced LHA from LGA 20 (10%)
Type III:Replaced RHA from SMA 22 (11%)
Type IV:Replaced LHA from LGA and Replaced
RHA from SMA
Type V: Accessory LHA from LGA 16 (8%)
Type VI: Accessory RHA from SMA 14 (7%)
Type VII: Accessory LHA from LGA+ accessory
RHA from SMA
Type VII: Accessory LHA from LGA and replaced
RHA from SMA; replaced LHA from LGA and
accessory RHA from SMA
Type IX: Replaced CHA from SMA 5 (2.5%)
Type X: Replaced CHA from LGA 1 (0.5%)
RHA right hepatic artery, LHA left hepatic artery, SMA superior mesen-
teric artery, LGA left gastric artery, RGA right gastric artery, CHA common hepatic artery
Table 17.2 Terminology of CRL classication system
Label Description
CHA(C_) Origination of CHA
C Celiac trunk
C
A
C
L
C
S
C
O
RHA(R_) Origination of RHA
R PHA or CHA
R
rA/RaA
R
rC/RaC
R
rG/RaG
R
rS/RaS
R
rO/RaO
LHA(L_) Origination of LHA
L PHA or CHA
L
rG/LaG
L
rL/LaL
L
rO/LaO
Aorta
LGA
SMA
Other arteries
Aorta
Celiac trunk
GDA
SMA
Other arteries
GDA
LGA
Other arteries
aRHA arises from gastroduodenal artery (GDA); R
Michel’s
classication
110 (55%)
2 (1%)
2 (1%)
4 (2%)
rS/RaS
,
rRHA/aRHA arises from SMA; and RrO/RaO, rRHA/aRHA
arises from other arteries.
L, Lr_ and La_ describe the origin of the LHA, replaced
LHA (rLHA) and accessory LHA (aLHA) respectively, with
origins specied: L alone, LHA arising from PHA or CHA;
LrG/LaG, rLHA/aLHA arises from GDA; LrL/LaL, rLHA/
aLHA arises from LGA; and LrO/LaO, rLHA/aLHA arises
from other arteries.
An accessory hepatic artery is one that arises from an
anomalous origin and supplies a portion of the liver along
with another artery. A replaced hepatic artery is one that
424
Fig. 17.2 Nomenclature rules of the CRL classication system and examples of hepatic artery description based on this system. (a) Nomenclature
rules for the common hepatic artery (CHA), right hepatic artery (RHA); (b) description of hepatic artery
J. Wang et al.
arises from an anomalous origin and supplies a portion of the
liver solely; the LHA and RHA arising from the PHA or
CHA are the only arteries supplying blood to the left lateral
lobe and right lobe of the liver, respectively. An additional
artery associated with the LHA or RHA would be referred to
as the aLHA or aRHA. An additional artery would be
referred to as the rLHA/rRHA, if one of the primary hepatic
arteries (LHA or RHA) was not present (Table17.2).
Every hepatic artery pattern can be expressed like
“C_R_L_”. For example, “CRrCLaL” means replaced RHA
arises from celiac trunk and accessory LHA originates from
LGA.
To simplify the CRL classication system and make it
more practical, 25 types of hepatic arteries were summarized
into 9 major categories as follows (Fig.17.3):
• Type 1 (CRL) The normal anatomy, CHA arises from the
celiac trunk, and LHA and RHA arise from PHA.
• Type 2 (CR
L) rRHA is the only aberrant artery with no
r
concomitant with other arteries. rRHA arises from the
aorta (2a), celiac trunk (2c), GDA (2g), SMA (2s), or
other arteries (2o).
• Type 3 (CRaL) Accessory RHA is the only aberrant
artery, aRHA arises from the aorta (3a), celiac trunk (3c),
GDA (3g), SMA (3s), or other arteries (3o).
• Type 4 (CRLr) rLHA is the sole aberrant artery, rLHA
arises from GDA (4g), LGA (4l), or other arteries (4o).
• Type 5 (CRLa) Accessory LHA is the sole aberrant
artery, aLHA arises from GDA (5g), LGA (5l), or other
arteries (5o).
• Type 6 (CR
) The type of replaced RHA concomitant
rLr
with replaced LHA.Accordingly, it could be understood
as Type 2 combined with Type 4.
• Type 7 (CRrLa/CRaLr) In Type7r, replaced RHA concomitant with accessory LHA (Type 2 + Type 5). In
Type7a, accessory RHA concomitant with replaced LHA
(Type 3 + Type 4).
• Type 8 (CRaLa) Accessory RHA concomitant with accessory LHA (Type 3+Type 5).
• Type 9 (C_RL) Replaced CHA is the only aberrant
artery, it arises from the aorta (9a), LGA (9l), SMA (9s)
or, other arteries (9o).
The middle hepatic artery (MHA), dened as the artery
that originated from RHA, LHA, or PHA at the hepatic
hilum and supplied segment IV of the liver (Michels 1966a,
b; Miyayama etal. 2005; Kobayashi etal. 1999; Wang etal.
2010), could be detected in 68.7% of patients (Yan et al.
2020a, b). Precise evaluation of hepatic artery patterns to
know about its origination, pathway, and its supplying segments will be vital for surgical planning to avoid iatrogenic
hepatic artery injuries.
Portal Vein Variations
Portal vein variations are observed in approximately 20% of
the population (Atri etal. 1992) (Fig.17.4). There are four
most common types of portal vein.
• Type I Classical anatomy. The main portal vein is divided
into left and right portal veins.
T
d
CHA from Aorta
CHA from LGA
CHA from SMA
T
T
T
T
T
T
17 Application of3D Visualization Technology inPerihilar Surgery
ype 1 (CRL)
425
CHA from Celiac trunk, LHA and RHA from PHA
1 (CRL)
ype 2 (CRrL)
AL)
2a (CRr
rRHA from Aorta
ype 3 (CRaL)
3c (CRa
aRHA from Celiac trunk
ype 4 (CRLr)
ype 5 (CRLa)
2c (CRr
CL)
rRHA Celiac trunk
CL)
aRHA from GDA
4g (CRLr
G)
rLHA from GDA
5g (CRLa
G)
aLHA from GDA
3g (CRaGL)
rLHA from LGA
2g (CRrGL)
rRHA from GDA
3s (CRaSL)
aRHA from SMA
4l (CRLrL)
5l (CRLaL)
aLHA from LGA
2s (CRrSL)
rRHA from SMA
ype 6 (CRrLr)
ype 7 (CRrLa/CRaLr)
7ac (CRrCLaL)
rRHA from Celiac trunk
and aLHA from LGA
6c (CRr
rRHA from Celiac trunk
and rLHA from LGA
7ag (CRr
rRHA from GDA and
aLHA from LGA
GLaL)
CLrL)
6g (CRLrGLrL)
rRHA from GDA and
rLHA from LGA
7as (CRrSLaL)
rRHA from SMA
and aLHA from LGA
6s (CRrSLrL)
rRHA from SMA and
rLHA from LGA
7rc (CRaCLrL)
aRHA from Celiac trunk
and rLHA from LGA
7rg (CRaGLrL)
aRHA from GDA and
rLHA from LGA
7rs (CRaSLrL)
aRHA from SMA an
rLHA from LGA
Type 8 (CRaLa)
8c (CRa
aRHA from Celiac trunk and
aLHA from LGA
CLaL)
8s (CRaSLaL)
aRHA from SMA and
aLHA from LGA
Type 9 (CxRL)
9a (C
ARL)
9I (CLRL)
9s (CSRL)
Fig. 17.3 Schematic diagram of CRL classication system
426
Fig. 17.4 Normal portal vein
variants
J. Wang et al.
Type IType II Type III
Type VIType VType IV
• Type II Portal vein trifurcation. The portal vein is divided
into three branches: right anterior portal vein, the right
posterior portal vein, and the left portal vein.
• Type III The right posterior portal vein arises from the
lower position of the portal trunk, and the trunk subsequently divides into a left and right anterior branch.
• Type IV The right anterior portal vein arises from the left
portal branch.
• Type V Absent left extrahepatic portal vein (Germain
etal. 2014; Atri etal. 1992).
In the right hemihepatectomy for a type III portal vein
variant, the right posterior branch may easily be mistaken for
the right branch and inadvertently ligated, leading to incomplete severe of portal venous ow of the right liver
(Fig.17.5a). The reason is that the right posterior branch of
the portal vein arises from a very low position of the portal
trunk, and then the trunk ramies further, forming the left
branch and right anterior branch. In the case of left hemihepatectomy for a type IV portal vein variant, the common
trunk of the right anterior branch and left branch may easily
be mistaken for the left branch and inadvertently ligated,
leading to injury of the right anterior portal branch; and subsequently ischemic damage to hepatic segments V and VIII
(Fig.17.5b). The reason is that the right anterior branch and
the left branch of the portal vein conuence to form a common trunk and then merge with the right posterior portal
branch. Absence of an extrahepatic left portal vein is a rare
anomaly, which results in the inability to perform right hemihepatectomy, but it does not affect left hepatectomy
(Fig.17.5c).
Bile Duct Variations
The conuence variation of the right hepatic duct is found in
34%–44% of population (Varotti et al. 2004; MariolisSapsakos etal. 2012). Varotti et al. (2004) divided the bile
duct into four types (Fig.17.6).
• Type 1 Normal type, the right anterior and right posterior
hepatic ducts converge to form the right hepatic duct, and
then converge with the left hepatic duct to form the
hepatic common duct.
• Type 2 Triple conuence, the right anterior hepatic duct,
right posterior hepatic duct and left hepatic duct simultaneously converge into the hepatic common duct.
• Type 3a The right anterior hepatic duct drains into the left
hepatic duct. Type 3b, the right posterior hepatic duct
drains into the left hepatic duct.
• Type 4a The right anterior hepatic duct enters directly
into the hepatic common duct. Type 4b, the right posterior
hepatic duct passes directly into the common hepatic
duct.
The conuence of the right hepatic duct is similar to that
of the portal vein, which affects the surgical planning. For
example, when the right anterior hepatic duct merges into the
left hepatic duct, the resection line should be located at the
right anterior hepatic duct conuence point far from the portal
side when the left hemihepatectomy is performed, in order to
prevent damage to the right anterior hepatic duct (Fig.17.7).
The incidence of left hepatic duct conuence variation
was about 41%, and the left hepatic duct conuence was
classied into three types (Cho etal. 2003) (Fig.17.8).
17 Application of3D Visualization Technology inPerihilar Surgery
427
a
b
c
Fig. 17.5 Special portal vein variation and surgical planning. (a) The
position where the portal vein is severed in the right hemihepatectomy
for a type III portal vein variant; (b) The position where the portal vein
is severed in left hemihepatectomy for a type IV portal vein variant; (c)
Fig. 17.6 Common pattern
of right hepatic duct
conuence. RAHD right
anterior hepatic duct, RPHD
right posterior hepatic duct,
LHD left hepatic duct, RHD
right hepatic duct, CHD
common hepatic duct
The position where the portal vein is severed when left hemihepatectomy is performed for the absence of the left hepatic segment of the
portal vein. The green dotted line indicates the correct position, while
the red dotted line indicates the wrong position