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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_585_Библиотеки_им_академика_М_И_Перельмана.pdf
438
J. Wang et al.
Fig. 17.21 Individualized three-dimensional visualization model of hepatic arteries based on CRL classication system
17 Application of3D Visualization Technology inPerihilar Surgery
Fig. 17.22 3D model of the portal vein
439
Fig. 17.23 3D model of the bile duct
vein sagittal part is L-UP, R-UP, or combined type. It can
avoid inadvertent intraoperative injuries to the left hepatic
artery and provide bases for judging the tumor invasion of
the left hepatic artery (Shimizu etal. 2014) (Fig.17.27).
17.5.1.8 Display ofP andU Points
P and U points are portals extending from the primary hepatic
duct to the secondary hepatic duct. The three-dimensional
reconstruction of the relationship between tumor boundary
and location of P and U points, as well as the threedimensional reconstruction of the spatial relationship
between the lesion and hepatic artery and portal vein, are
important bases for planning of the resection range and formulation of the surgical plan (Fig.17.28). The reconstruction
of P and U points fully reects the advantages of threedimensional visualization.
440
ab
Fig. 17.24 Three-dimensional visualized model of the spatial relationship of extrahepatic vessels. (a) The right hepatic artery runs in front of the
common liver; (b) The hepatic artery passes behind the portal vein. Hepatic artery (red); Portal vein (blue); Bile duct (green)
J. Wang et al.
abc
Fig. 17.25 Three-dimensional visualized model of spatial relationship between the right posterior hepatic artery and the right portal vein. (a)
Infraportal type; (b) Supraportal type; (c) Combined type. Note: Hepatic artery (red); Portal vein (blue)
a
b
c
Fig. 17.26 Three-dimensional visualized model of spatial relationship between right posterior hepatic duct and right portal vein. (a) Supraportal
type; (b) Infraportal type; (c) Combined type. Note: Portal vein (blue); Bile duct (green)
17 Application of3D Visualization Technology inPerihilar Surgery
ab
cd
441
Fig. 17.27 Three-dimensional visualized model of the spatial relationship between the left hepatic artery and the sagittal part of the portal vein.
(a) L-UP type, (b) R-UP type, (c, d) combined type
a
Fig. 17.28 P and U points. (a) P point (lateral view), (b) U point (ventral view). Note: Hepatic artery (red); Portal vein (blue); Bile duct (green)
b
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J. Wang et al.
17.5.2 Preoperative Evaluation ofPerihepatic
Hilar Diseases Based on3D
Visualization Technology
17.5.2.1 Preoperative Evaluation ofPerihepatic
Hilar Tumor Based on3D Visualization
Technology
Preoperative assessment of perihepatic hilar tumors is basically similar. We shall take hilar cholangiocarcinoma as an
example, which is elucidated as follows. The preoperative
evaluation of hilar cholangiocarcinoma focuses on the evaluation of tumor resectability (whether the tumor can achieve
radical resection). The evaluation includes four dimensions:
the extent of tumor extending along the bile duct; the invasion of adjacent hepatic artery, portal vein, and liver parenchyma; lymph node metastasis and distant metastasis (Xiang
and Dong 2009; Ni etal. 2015). Three-dimensional visualization is of great value in evaluating the extent of tumor
involving bile duct, tumor invasion of hilar vessels, and
residual liver volume after hepatectomy, but there is no obvious advantage in the evaluation of lymph node metastasis
and distant metastasis (Ni etal. 2016).
Evaluating theExtent ofTumor Involvement inBile
Ducts by 3D Visualization
The Bismuth-Corlette classication (Bismuth and Corlette
1975) is currently the most widely used hilar bile duct clas-
sication, which can be divided into four types (Figs.17.29
and 17.30). Type I: The tumor is located in the common
hepatic duct and does not violate the conuence. Type II:
The tumor invades the right and left hepatic duct conuence
but does invade the left and right hepatic ducts; Type III: The
tumor invades the right hepatic duct (type IIIa) or left hepatic
duct (type IIIb); Type IV: The tumor simultaneously invades
the left and right bile ducts.
Three-dimensional visualization technology can not only
visualize the size of tumors and extent of bile duct involvement, but also evaluate whether the tumor boundary exceeds
P and U points (the separation limits of the bile duct)
(Fig. 17.31). Sakamoto et al. (1998) showed that the safe
length of the negative margin is more than 5mm from the
tumor margin. Three-dimensional visualization technology
can be used to measure the safe length of bile duct through
simulated surgery.
Bismuth-Corlette classication is based on the extent of
bile duct involvement by tumors, which is of great value for
the selection of surgical approach. However, it does not
assess the factors such as vascular invasion, lymph node
metastasis, and liver atrophy that have an impact on the
resection and prognosis of hilar cholangiocarcinoma. A new
staging system for hilar cholangiocarcinoma was proposed
by the International Cholangiocarcinoma Association in
2011, which comprehensively evaluates and expresses the
pathological elements such as the location and shape of cholangiocarcinoma tumors, the involvement of portal vein and
hepatic artery, reserved liver volume, liver parenchymal
lesions, lymph nodes, and distant metastasis. Threedimensional visualization technology is more suitable for the
application of this classication.
Evaluating theTumor Invasion ofHilar Vessels by 3D
Visualization Technology
The criteria for judging vascular involvement are as follows:
the vessel is surrounded by tumor, resulting in obstruction,
narrowing or contour distortion of the lumen. The angle of
tumor contact with blood vessel is more than 180° (Lu etal.
1997; Park et al. 2008). Three-dimensional visualization
technology can visualize whether the tumor wraps around
the blood vessels and whether the blood vessels become
thinner under pressure; which can intuitively and accurately
Fig. 17.29 The BismuthCorlette classication of hilar
cholangiocarcinoma (Soares
etal. 2014)
17 Application of3D Visualization Technology inPerihilar Surgery
Fig. 17.30 The Bismuth-Corlette classication of hilar cholangiocarcinoma based on 3D visualization technology. Note: Bile duct (green), tumor
(yellow)
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Fig. 17.31 3D visualization technology is used to display P and U
Points
show the relationship between the tumor and the hepatic
artery and portal vein (Endo etal. 2007) (Fig.17.32).
3D Visualization Classication ofHilar
Cholangiocarcinoma
The Expert Consensus on Accurate Diagnosis and Treatment
of Hilar Cholangiocarcinoma with Three-Dimensional
Visualization (2007 edition) (Lau etal. 2017a, b) proposed
the clinical classication of hilar cholangiocarcinoma with
3D visualization, which has important guiding value for
accurate diagnosis and treatment. The classication divides
hilar cholangiocarcinoma into ve types: Type I: tumors
invade the common hepatic duct, not the conuence of left
and right hepatic ducts, no invasion of hepatic artery and portal vein, no atrophy of hepatic region or segment; Type II:
tumors invade the conuence of left and right hepatic ducts,
with or without invasion of hepatic artery and portal vein,
and with or without atrophy of hepatic region or segment.
Type III a: tumors invade the conuence of left and right
hepatic ducts, mainly the right hepatic duct, accompanied by
right hepatic artery or right portal vein branch invasion, with
or without atrophy of right hepatic area or segment; Type III
b: tumors invade the conuence of left and right hepatic
ducts, mainly the left hepatic duct, accompanied by left
hepatic artery or left portal vein branch invasion, with or
without left hepatic duct atrophy; type IV a: tumors invade
the conuence of left and right hepatic ducts, the right secondary bile ducts, the right hepatic artery or the right branch
of portal vein, but not beyond the scope of point P, the right
hepatic region or segment atrophy; type IV b: tumors invade
the conuence of left and right hepatic ducts, the left secondary bile duct, the left hepatic artery or the left branch of portal vein, but not beyond the scope of point U, with or without
atrophy of the entire liver.
Preoperative Evaluation ofCentrally Located
Hepatocellular Carcinoma Based on3D Visualization
Technology
The centrally located hepatocellular carcinoma has a special
position and is closely related to the hepatic blood vessels
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ab
J. Wang et al.
Fig. 17.32 3D visualization shows the relationship between hilar cholangiocarcinoma, and adjacent hepatic arteries and portal veins. (a) The
ventral view shows tumor invasion of the right hepatic artery and the
and bile ducts. Surgery often requires major hepatectomy
and the risk is high. The preoperative assessment focuses on
the location of the tumor, the invasion of hepatic artery, portal vein and bile duct, and the extent of hepatic parenchymal
involvement.
In 2017, “The Expert Consensus on Accurate Diagnosis
and Treatment of Complicated Liver Tumors with ThreeDimensional Visualization,” proposed the clinical classication of centrally located hepatocellular carcinoma with 3D
visualization based on the location of the carcinoma, the
relationship between the tumor and intrahepatic vessels, and
the hepatic segment to be resected; which has important
guiding value for accurate diagnosis and treatment of centrally located hepatocellular carcinoma (Lau etal. 2017a, b;
Tao 2016). Centrally located hepatocellular carcinomas are
divided into ve categories:
portal vein, and portal vein stenosis. (b) Three-dimensional images displayed on the cephalic side
branch of the portal vein. Segments IVa, IVb±segments
V and VIII should be resected. In case of sufcient residual liver volume, segment IV, V, and VIII of the liver could
also be resected.
• Type IV: This type of liver tumor occupies the most liver
parenchyma of segments IV, V, and VIII, characterized by
their close proximity to, or a direct violation of, the left/
right portal vein trunk or the left/right hepatic vein. In
case of sufcient residual liver volume, right trisectionectomy or left trisectionectomy can be performed; while if
the volume of the residual liver is not enough, and the
portal vein and hepatic vein meet the requirements, it is
feasible to perform reduced right trisectionectomy or
reduced left trisectionectomy.
• Type V: This type of liver tumor occupies the supercial
liver parenchyma of segments IV, V, and VIII and the
lesion does not invade either the portal branch or the
• Type I: The tumor was located in segments V and VII
and invaded portal vein branches but did not invade the
hepatic vein. Thus, hepatectomy with negative margin
should be performed (Fig.17.33).
right main branch of the portal vein. The hepatic segments V and VII should be resected with partial
hepatectomy.
• Type II: The tumor was located in segment IVa and IVb.
The tumor invaded the branch of the portal vein but did
not invade the main trunk of the left branch of the portal
vein. The resection of segments IVa and IVb of liver
17.5.2.2 Preoperative Evaluation ofBenign
Diseases inthePerihilar Area Based
on3D Visualization Technology
Preoperative evaluation of benign perihepatic portal diseases
based on three-dimensional visualization technology should
include:
should be performed with partial resection of segments V
and VIII.
• Type III: The tumor occupies the most liver parenchyma
of segments IV, V, and VIII, characterized by a wide and
deep invasion of the parenchyma, or their proximity to the
middle hepatic vein. It invades some branches of the portal vein but did not invade the right branch or the left
• The location and extent of the lesion.
• The relationship of the lesion to the hepatic artery and
portal vein.
• The variation of hepatic portal bile duct, hepatic artery,
and portal vein.
• The volume of hepatic lobes and segments.
a
MHV
17 Application of3D Visualization Technology inPerihilar Surgery
445
IVC IVC
LHV
MHV
IVC
RAPV
Fig. 17.33 3D visualization of the centrally located hepatocellular carcinoma. (a–e) Type I–V. MHV middle hepatic vein, IVC inferior vena cava,
LHV left hepatic vein, LPV left portal vein, RHV right hepatic vein, RAPV right anterior portal vein
cd
RHV
LHV
LPV
LPV
RHV
RAPV
MHV
IVC
LHV
MHV
RAPV
LHV
LPV
b
IVC
MHV
e
LHV
LPV
Preoperative evaluation of the hepatolithiasis mainly
includes the size of stones and their distribution in various
bile ducts, the extent and scope of the bile duct stenosis and
dilatation, liver atrophy and hypertrophy, and the function of
the Oddi sphincter. Three-dimensional visualization is of
great value in evaluating the distribution of hepatolithiasis,
the location of biliary stenosis and dilatation, and the residual liver volume after hepatectomy (Fang etal. 2010, 2013,
2015).
Based on the Guidelines for Diagnosis and Treatment of
Hepatolithiasis, the “Expert Consensus on Accurate
Diagnosis and Treatment of Hepatolithiasis with Threedimensional Visualization” (2017 version) (Fang etal. 2015)
further standardized the establishment of the threedimensional visualization model of hepatolithiasis; providing a new strategy for the accurate diagnosis and treatment of
hepatolithiasis.
In the preoperative evaluation of high biliary stricture and
central bile duct cystic dilatation; 3D visualization technology can also visualize the location and scope of the lesion
and the relationship between the lesion and blood vessels;
providing basis for the formulation of surgical planning.
17.5.2.3 Liver Segmentation andResidual Liver
Volume Evaluation Based on3D
Visualization Technology
The Couinaud classication is currently the most widely used
method for liver segmentation, which applies three hepatic
venous ssures and hepatic transverse ssures as anatomical
markers. The hepatic vein ows through the adjacent hepatic
segments and drains blood from each segment, while the portal vein walks through the segments of the liver according to
its branches, supplying each segment with blood. Each
hepatic segment is an independent anatomical functional unit.
Couinaud divides the liver into the left and right half, four
sectors, and eight segments according to the course of the
hepatic vein and portal vein. The liver is divided into left and
right liver by the plane where the middle hepatic vein is
located. The left and right halves of the liver are divided into
four sectors, respectively, by the plane where the left hepatic
vein and right hepatic vein are located and the inferior vena
cava are located, namely: the left paramedian sector, left lateral sector, right paramedian sector, and right lateral sector
(Fig. 17.34). The left and right branches of the portal vein
serve as transverse boundaries, dividing the four sectors into
eight segments. However, the Couinaud classication also
has certain limitations. It is applicable to the liver segmentation of a normal portal vein. If there is variation in the portal
vein, the segment plane needs to be adjusted according to the
distribution and course of portal vein branches.
The segmentation of hepatic segments or sectors and the
measurement of each hepatic volume were performed by 3D
visualization technology, mainly based on the course of the
hepatic vein and portal vein (Fig.17.35).
Before hepatectomy, partial hepatectomy can be performed by simulated surgery, and residual liver volume can
be measured to evaluate surgical safety (Wigmore et al.
2001; Rau etal. 2000).
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Fig. 17.34 Couinaud classication of hepatic segments
Fig. 17.35 Segmentation of the liver based on 3D visualization
technology
J. Wang et al.
By means of 3D visualization technology, the liver contour, the range of lesion, portal vein, hepatic vein, hepatic
artery, and bile duct, can be displayed and arbitrarily combined, rotated, zoomed in, and zoomed out. It can also visualize the conuence, course, and variation of these vessels.
The spatial location of a tumor can be displayed, achieving
all-round observation of hepatic segment involving the
tumor; and the relationship of the tumor with its adjacent
vessels, measurement of incision length, calculation of residual liver volume, simulation of surgical approach, and prediction of the important vascular structures that may be
encountered during the operation. Thus, per-hepatic portal
surgery can be better visualized, quantiable, and
controllable.
17.5.3.2 Intraoperative Navigation
ofPerihepatic Hilar Diseases Based
on3D Visualization Technology
Computer-aided surgery (CAS) has realized real-time 3D
positioning during the surgical procedure by using 3D visualization. Through registration of preoperative and intraoperative medical images, as well as registration of
intraoperative medical images with patients and surgical
instruments; the dynamic three-dimensional space between
surgical instruments and pathological tissues and normal
anatomical structures, and whether the surgical procedure
and results are consistent with the preoperative simulation,
can be accurately judged. Thereby achieving real-time intraoperative navigation and more precise and minimally invasive surgery; opening up a new eld for the development of
surgical technology. Currently, an obstacle to the application
of 3D navigation surgery in perihepatic hilar disease surgery
is the plasticity of viscera. During laparotomy, the shape of
liver and biliary tract is easily distorted, so the registration
fails. With the improvement of technology, it is believed that
in the near future, intraoperative navigation surgery will also
be applied to the operation of perihepatic hilar diseases,
especially in laparoscopic and robotic surgery.
17.5.3 Simulated Surgery andIntraoperative
Navigation ofPerihepatic Disease
Based on3D Visualization Technology
17.5.3.1 Surgical Planning andSimulation
ofPerihepatic Disease Based on3D
Visualization Technology
Preoperative evaluation of peri-hepatic disease based on conventional imaging examination has high requirements for the
surgeon’s anatomical knowledge and spatial perception, with
subjective and uncertain factors. It cannot sufciently assess
the complex vascular structure of the perihilar area, the inltration range of lesions, or the residual liver volume after
hepatectomy, before operating. Many important decisions
need to be made during the operation.
17.6 3D Visualization Imaging
17.6.1 Third-Party Software for3D
Visualization Processing
The processing software for CT cannot satisfy the needs of
three-dimensional reconstruction of clinical images, so some
researchers have successively designed independent software for preoperative imaging evaluation and surgical planning of the hepatobiliary system. In some cases, intraoperative
navigation can also be achieved.
Materialize Mimics is the relatively famous three-
dimensional visualization software in the early stage created
17 Application of3D Visualization Technology inPerihilar Surgery
447
by Materialize Medical. However, at this time, Mimics lacks
a module for designing the part of a liver and the threedimensional processing requires this to be rendered manually, which is time consuming, laborious, and ineffective.
The HepaVision system (Mevis, Germany) has a high quality
of image reconstruction. Domestic users can apply for their
services through their websites. They only need to transmit
the source data in DICOM format to Mevis Research Group
through the network. The other party will analyze the data
and feedback the results of three-dimensional visualization
processing to users. However, the service fee is expensive. In
addition, users lack the autonomy of image data reconstruction and analysis.
At present, the IQQA-LIVER system developed by
EDDA Company in the United States and the Myrian-XP
system developed by Intrasense Company in France is
widely used in China.
The team led by Professor Chihua Fang of Southern
Medical University has also developed an MI-3DVS system
with independent intellectual property rights (Zhu et al.
2008; Fang et al. 2004). In the MI-3DVS system, source
images in DICOM format are used for processing and the
region of interest (ROI) is identied and marked through a
combination of automatic and manual methods. Automatic
segmentation technology can signicantly reduce the workload of manual segmentation. The biggest advantages compared with CT/MRI processing software, are strong manual
segmentation and modeling functions. Each region of interest can generate a model (mask), and multiple masks can be
combined to express three-dimensional information. Similar
to other three-dimensional visualization software, hepatic
artery, portal vein, bile duct, hepatic vein, and lesion, can be
displayed in the same image and arbitrarily combined as
needed. It can also measure the size of lesion and assess the
extent of lesion involvement, and use cutting plain image
processing to perform virtual surgery and observe the operative effect. The liver volume of each segment and the residual
liver volume of simulated surgery can be measured, providing an intuitive basis for preoperative evaluation and the formulation of surgical planning.
We present the IQQA-LIVER developed by EDDA company as an example to describe the key points of threedimensional visualization processing technology.
17.6.2 Technique of3D Visualization
Processing
17.6.2.1 Acquisition ofThin-Slice Enhanced CT
Data
3D visualization processing is based on enhanced CT of the
upper abdomen. Therefore, preoperative enhanced CT of
the upper abdomen is required for each patient to collect
the data from the: plain scan, arterial phase, venous phase,
and equilibrium phase. Scanning can be performed with 64,
128, 256, or 320 slice helical CT scanners. During routine
plain scan, patients were scanned in the supine position,
with a scan range from the top of the diaphragm to the
lower edge of the liver. Scanning conditions were 120kV,
250mA.A combination of 0.625mm×64-row detector is
adopted, with a layer thickness of 1.25mm, an interval of
1.25mm, a pitch of 0.984, and a rotation time of 0.5s for
the ball tube for 1cycle. Thinner layers are better for reconstruction. The delay time of arterial phase was 20~ 25 s,
and that of venous phase was 50~ 55 s. After scanning,
enhanced CT data can be saved in DICOM format for 3D
reconstruction.
17.6.2.2 Import ofImage Data
When the DICOM format CT image data is imported into the
workstation IQQA-LIVER system (EDDA Technology Inc.,
Princeton, NJ, USA), the workstation will automatically
generate a list of cases. And select the cases in the list
(Fig.17.36).
Fig. 17.36 Import CT data into the workstation and open the case interface