Three-dimensional visualization technology in preoperative planning of precise hepatectomy

Objective To evaluate the role of computer-assisted surgical planning system in liver resection for patients with hepatocellular carcinoma (HCC).Methods Between January 2010 and January 2012,21 patients with HCC who underwent liver resection were included in this study.Computer assisted operative planning was performed before surgery.Results Computer-assisted surgical planning was performed successfully in all the 21 patients.The three dimensional anatomic evaluation was precise and quantitative.The predicted liver resection volume showed a significant correlation with the actual volume,with a mean difference of 3.5％.The types of liver resection included anatomic liver resection (15 patients) and local resection (6 patients).There was a 0％ mortality and a 14.3％ morbidity (3/21).Conclusions The computer-assisted surgical planning system reliably analyzed the 3D vascular structures and predicted accurately liver resection volumes.It can help to promote precise and safe liver resection. Key words: Hepatectomy; Computer-aided design; Three-dimensional reconstruction; Liver neoplasms; Liver volume

Objective: To explore a novel method for preoperative precision assessment of centrally located hepatocellular carcinoma(HCC) with blood vessel as axis based on three-dimensional(3D) visualization and virtual reality(VR) technology and its application values. Methods: High-quality thin-layer enhanced CT data were collected from 20 patients with centrally located HCC who treated at First Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University from March 2017 to August 2018 diagnosed by preoperative examination. There were 18 males and 2 females, aged 28 to 69 years, all of Child-Pugh grade A. First of all, 3D reconstruction was performed by a 3D visualization software; then, the reconstructed 3D image was imported into VR development engine for VR research; afterwards, the analysis and evaluation system with blood vessel as axis was established based on 3D visualization classification of centrally located HCC; therefore, the relationship of the tumor to its major peripheral blood vessels was accurately judged and the surgical planning was formulated. Two images were brought into the operating room for navigation in surgery. The assessments results of preoperative data (CT and (or) MRI) and three-dimensional visualization of blood vessels in VR environment were compared; the values of the preoperative and postoperative hemoglobin, serum albumin and bilirubin were recorded and compared. Chi-square test, t-test and non-parametric test were used for the analysis of counting data, continuous measurement data and non-normal distribution measurement data, respectively. Results: 3D visualization modeling was completed in all of the 20 patients with centrally located HCC. According to the results of 3D visualization classification of centrally located HCC, there were 3 cases of type Ⅰ,1 case of type Ⅱ,4 cases of type Ⅲ,7 cases of type Ⅳ and 5 cases of type Ⅴ; according to the assessment and classification based on blood vessel as the axis, there were 6 cases of type Ⅰa,2 cases of type Ⅰb,2 cases of type Ⅱa,9 cases of type Ⅱb and 1 case of type Ⅱc. All patients underwent successful resection of tumor under the guidance of 3D visualization and VR technology. There were 15 cases whose assessment results based on preoperative CT/MRI were consistent with intraoperative findings, with a coincidence rate of 75.0%(15/20); while in VR environment, the assessment results of 3D visualization with blood vessel as axis were all consistent with the intraoperative findings, with coincidence rate of 100%(20/20). There was a statistically significant difference between the groups (χ(2)=5.714, P=0.017). There was no red blood cell transfusion in all patients during the operation. The preoperative hemoglobin was (128.8±14.9)g/L, and it was (119.8±12.5)g/L on postoperative day 1. There was no significant difference between these two sets of data (t=2.07, P=0.054). No death during the perioperative period and no complications such as hepatic failure, hemorrhage and biliary fistula after operation occurred. Conclusion: Preoperative evaluation based on 3D visualization and VR technology with blood vessel as the axis has significant clinical value for preoperative planning and surgical navigation of centrally located HCC.

Objective To study the application of three-dimensional simulated surgical technique in precise hepatectomy. Methods From July 2009 to February 2010, 16 patients with primary liver cancer underwent preoperative simulated imaging and three-dimensional simulation of liver resection.The 3D extent of simulated hepatectomy and actual hepatectomy was compared and analyzed. Results The shape and the extent of the liver resected were very similar in the simulated and the actual hepatectomies. The mean differences in the length, breadth and depth of the remnant livers were 0. 6118 cm,0. 4490 cm and 0. 3199 cm, respectively. Conclusions Simulation hepatectomy could predict the extent of the actual liver resection, and provided accurate guidance and preoperative planning for precise hepatectomy. Key words: Three-dimensional simulated surgery techniques; Precise hepatectomy; Liver carcinoma

Objective To evaluate the the safety and efficiency of precise liver resection for patients with primary liver cancer. Methods 86 patients with primary liver cancer were randomized to receive conventional routine hepatectomy (n=44) or the precise liver resection (n=42). Outcomes were compared between the precise hepatectomy group and the routine group, including, the blood loss, operation time, morbidity and mortality. Results There were significant differences in morbidity rates (7.1% vs. 20.5%; P<0.001), the blood loss [(320±315) ml vs. (613±526) ml;P<0.001) , postoperative alanine aminotransferase (ALT) value (in postoperation 7 d, 82.7 U/L vs.321.7 U/L; P<0.001) and length of hospital stay (12.3 d vs. 18.6 d; P<0.001) between precise hepatectomy and routine groups. The 1 year tumor recurrence rate and 1 year survival rate were 26.2%(11/42) and 78.6% (33/42) in precise liver resection group, 38.6% (17/44) and 65.9%(29/44) in routine liver resection group,with significant difference (P=0.010;P=0.018). Conclusion Precise liver resection is safe and effective in the treatment of liver tumor without much injury to patients. Key words: Liver neoplasm; Precise liver resection; Prognosis

Objective To summarize our experience on precise liver resection for giant pediatric hepatic neoplasms. Methods From January 2009 to February 2012,30 patients underwent precise liver resection technique for resection of giant hepatic neoplasm at West-China hospital of Sichuan Universi- ty. The patients,consisting of 17 boys and 13 girls,had an average age of 5.04 ＋ 3.50 years （range,2 months to 14 years）. Hepatic reserve function and radiologic study were evaluated carefully before sur- gery. Individualized surgical approach was carefully planned. Postoperative pathology diagnoses were hepatoblastoma in 13 ,focal liver hyperplasia in 5, hepatic hemangioma in 3, liver hamartoma in 3, and other in 6. The outcome of precise liver resection technique was evaluated by comparing with the out- come of conventional liver resections. Results Compared with conventional liver resection, patients un- derwent precise liver resections had less mean blood loss and blood transfusion （P~ 0. 01）, faster de- cline in alanine aminotransferase, sooner recovery in total bilirubin levels （P~ 0. 01）, and shorter ICU/hospital stays （P~ 0. 05）. The precise liver resections were associated with fewer complications than conventional liver resection. No liver failure, intra-abdominal bleeding, abdominal infection, or death was noted. Ten patients had minor complications, including mild bile leakage, hydrothorax, and pulmonary infection. Conclusions Precise liver resection is safe and effective for the treatment of giant hepatic neoplasms in children. Key words: Liver neoplasms Hepatectomy; Postoperative complications

To explore the application value of computer-assisted preoperative planning of hilar cholangiocarcinoma. Retrospective analyses were conducted for the clinical data of 47 patients with hilar cholangiocarcinoma undergoing radical resection plus hemihepatectomy from January to December 2013. According to whether computer-assisted preoperative planning was used, they were divided two groups of computer-assisted surgical planning (CASP) and without computer-assisted surgical planning (WCASP). Then we analyzed the data including preoperative examinations, preoperative planning, intraoperative findings and postoperative complications. There were 31 cases of hilar vascular invasion by tumor. Among 29 cases of CASP, left hepatic artery originated from left gastric artery (n = 6), right posterior bile duct drained into left hepatic bile duct (n = 1) and right posterior bile duct run into common hepatic bile duct (n = 2). The mean operative duration of CASP was (6.5 ± 1.3) h and the mean volume of intraoperative bleeding (672.0 ± 214.3) ml; while the mean operative duration of WCASP was (7.9 ± 2.9) h and the mean volume of intraoperative bleeding (870.0 ± 330.1) ml. By statistical analysis, the inter-group differences of mean operative duration had statistical difference (P = 0.028) and the inter-group differences of mean volume of intraoperative bleeding had statistical difference (P = 0.016). The ratio of first negative test in group CASP was higher than that of group WCASP and the inter-group differences had statistical significance (P = 0.043). But the inter-group rate of postoperative complications had no significant difference (P = 0.419). The computer-assisted surgical planning system provides accurate information so that an optimal surgical protocol may be designed by surgeons. And it has great application values in preoperative surgical planning for hilar cholangiocarcinoma and enjoys wide prospects in precise liver surgery.

Objective To evaluate the clinical application of Helix water-jet dissector in complex hepatectomy. Methods Clinical data were retrospectively analyzed in 47 patients who received complex hepatectomy using Helix water-jet dissector for the parenchymal division. It was evaluated for the intraoperative blood loss, operation time, postoperative hepatic function and complications in these patients.Results Forty seven patients including 10 cases of hepatic giant cavernous hemangioma, 34 cases of hepatocellular carcinoma, and 3 cases of miscellaneous liver tumors. Among these patients, caudate lobe resection was performed in 6 cases, hepatic segment Ⅵ + Ⅷ resection in 19 cases, segment Ⅳ + Ⅴ + Ⅷresection in 9 cases, segment Ⅷ resection in 5 cases and right hepatic trisegmentectomy in 8 cases. The operation time was (240 ±85) min, intraoperative blood loss was (950 +650) ml, 13 out of 47patients (27.7%) received heterologous packed red blood cell (PRBC) transfusion for more than 2 units per case.Length of stay in hospital was ( 12. 5 ±4. 7) days. Post-operative complications included ascites in 6 cases,hydrothorax in 4 cases, atelectasis in 2 cases and pulmonary infection in 4 cases. No severe complications and death occurred in this group. Conclusion Water-jet dissector may increase operation accuracy,decrease massive blood loss and postoperative complications, therefore, it should be widely used in complex hepatectomy. Key words: Hepatectomy; Postoperative complications; Helix water-jet

Objective To evaluate the clinical value of three-dimensional reconstruction and virtual hepatectomy for laparoscopic precise liver resection of right liver tumor. Methods 31 cases of right liver tumor from June 2012 to October 2015 at Department of Hepatobiliary Surgery in Affiliated Hospital of Nantong University, were analyzed retrospectively. Patients were divided into three dimensional reconstruction group (n=15) and control group (n=16), Operation time, bleeding volume during operation, postoperative complications and days of hospitalization after operation in two groups were observed. Results All operation was successfully performed with pure laparoscopic right liver tumor resection in three dimensional reconstruction group. In control group, 1 case was completed by hand-assisted laparoscopic liver resection, 1 case was converted to open operation, the remaining 14 cases underwent total laparoscopic right liver tumor resection. Operation time in 3-dimensional reconstruction group was (141±36)min vs. (207±66)min in control group, bleeding volume was (274±88)ml vs.(418±189)ml, hospitalization after operation was (9±3)days vs.(13±6)days (all P<0.05). Conclusions Preoperative three-dimensional reconstruction and virtual hepatectomy can ensure the localization of parenchyma tumor during the laparoscopic precise liver resection, clarifing the relationship between tumor operation section and peritumoral vascular or biliary ducts, fulfilling the idea of precise liver resection. Key words: Liver neoplasm; Hepatectomy; Laparoscopes; Imaging, three-dimensional

Objective To evaluate the safety and efficacy of precise hepatectomy techniques in hepatolithus. Methods Ninety-two patients with hepatolithus undergoing hepatectomy from January 2008 to October 2012 were reviewed retrospectively. Thirty-two patients received irregular hepatectomy (control group) and 60 received precise hepatectomy (experimental group), and the intraoperative and postoperative indexes such as operative time, intraoperative blood loss, postoperative liver function, length of hospital stay, incidence of complications and clearance rate of calculus were analyzed. Results In experimental group, the operative time was longer [(262.2±54.2)min vs (174.8 ±54.8)min, t=30.727, P<0.01], but the patients had reduced intraoperative blood loss [(438.5±89.6)ml vs (680.6±74.7)ml, t=-86.465, P<0.01], faster recovery of liver function [ALT value on POD 7, (50.1±7.4) U/L vs (320.7±11.8) U/L, t=-96.470, P<0.01], less postoperative complications(11.7% vs 40.6%, χ2=10.227, P<0.01), higher clearance rate of calculus(100.0% vs 75.0%, χ2=16.429, P<0.01)and shortened length of hospital stay [(15.9±5.4) d vs(23.4±4.3) d, t=-50.103, P<0.01]. Conclusions Precise hepatectomy is safe and effective in the treatment of hepatolithus without much injury to patients. Precise hepatectomy can significantly decrease postoperative complications, length of hospital stay, and accelerate the early rehabilitation. Key words: Hepatolithus; Hepatectomy/methods; Precise hepatectomy; Irregular hepatectomy

Objective To evaluate the feasibility and efficacy of ex-vivo liver resection combined liver autotransplantation for patients with massive primary liver cancer who underwent complex liver resection.Methods The clinical data of 4 patients suffering from massive primary liver cancer who were admitted to the Beijing Chaoyang Hospital from January 2008 to May 2010 were retrospectively analyzed.Regular liver resection could not be carried out because the first,second and third hepatic hilum of the 4 patients were invaded by the tumors,so ex-vivo liver resection combined liver autotransplantation were performed.Results The operation was successfully carried out for the 4 patients.The operation time,the duration of anhepatic phase and the volume of operative blood loss were 690-840 minutes,250-300 minutes and 400-1400 ml,respectively.Portacaval bypass operation was not performed.After ex-vivo liver resection,the inferior vena eava or hepatic vein and portal vein of the 4patients were repaired,and the allogenous blood vessels were kept to extend the superior vena cava of the remnant liver so as to facilitate the anastomosis of blood vessels and reconstruction of the first hepatic hilum. After operation,the hepatic function of 1 patient was back to normal; 1 patient who stfffered from abdominal hemorrhage received reoperation for hemostasia; 1 patient was found with hepatic dysfunction; 1 patient died of hepatorenal dysfunction at postoperative day 5.Compensatory hypertrophy was observed in the 3 patients who survived at postoperative months 1-2.Of the 3 patients,2 were found with multiple pulmonary metastases at postoperative months 8 and 9,and they died at postoperative mouths 13 and 15.Until April 2012,1 patient survived for 37 months with no tumor recurrence or metastasis. Conclusions Ex-vivo liver resection combined liver autotransplantation provides the technical feasibility for performing complex liver resection for patients. The incomplete compensation of liver function and the short-term recurrence of tumors after operation are still the main issues which hinder the development of this technique. Key words: Liver neoplasms; Ex-vivo liver resection; Liver autotransplantation

Objective To evaluate the clinical value of artificial hydrothorax combined with one-lung ventilation to aid ablation treatment of liver carcinoma in the hepatic dome. Methods Twenty-one patients with liver carcinoma located in the hepatic dome and affected by the lung gas were enrolled. Double lumen endobronchial intubation anesthesia was used and thoracical tube was used to apply artificial pleural effusion. The lesions'ultrasound image were recorded for the patients without artificial hydrothorax, or with artificial hydrothorax only and artificial hydrothorax combined with one-lung ventilation. Ultrasound images were reviewed and scored as 1-5 according to the clarity and completeness of the lesion. Ablation efficacy and adverse reactions were recorded in the follow-up. Results Twenty-one patients were successfully applied artificial hydrothorax and one-lung ventilation. The average normal saline used for artificial hydrothorax were (738±260)ml. The ultrasound score for not using artificial hydrothorax, using artificial hydrothorax only and artificial hydrothorax combined with one-lung ventilation were 1.13±0.35(1-2), 3.00±0.85(2-5) and 4.53±0.64(3-5), respectively, statistical difference was found between each method(P<0.05). Artificial hydrothorax combined with one-lung ventilation had much higher ultrasound score than the other 2 methods. No complication related to artificial hydrothorax or one-lung ventilation was found. CT/MRI at one month after ablation showed that all the lesions were completely ablated. In the follow-up for 2-14 months on average, 1 case of local tumor progression and 1 case of intrahapetic relapse were found. Conclusions Artificial hydrothorax combine one-lung ventilation could effectively enhance ultrasound image for the lesions in the dome whose acoustic window was affected by lung gas. Key words: Ultrasongraphy; Liver neoplasms; Catheter ablation; One-lung ventilation; Artificial hydrothorax

Objective To explore the relationship between liver tumors and hepatic veins in children and assess the clinical value of computer-assisted surgery (CAS) system for pediatric liver surgery. Methods The clinical data of 27 cases with liver tumors at second hepatic portal area was analyzed from January 2013 to June 2017.There were 19 boys and 8 girls aged from 2 months to 10 years with a mean age of (2.3±2.9) years.Maximal and median diameters of tumor were 21.0 cm and 10.2 cm respectively.Prior to surgery, liver three-dimensional reconstruction by Hisense CAS was performed to observe the relationship between intrahepatic vessels and liver tumor and calculate the intended resection range and the remaining liver volume.Intrahepatic vascular shape and variation, surgical approach, operative duration, blood loss, intraoperative blood transfusion and postoperative complications were observed. Results According to preoperative three-dimensional reconstruction, tumors invaded single (n=5), two (n=1) and three main hepatic veins (n=1). Among 20 cases of oppressed main hepatic vein, inferior vena cava was oppressed in one case and another case had diffuse total hepatic lesion.Right hepatectomy (n=11), left hepatectomy (n=3), left trisectionectomy (n=3), mesohepatectomy (n=7) and right anterior lobe resection (n=3) were performed.The median tumor volume was (10.67×8.57×6.48) cm3, median operative duration 162 (60-260) min, median blood loss 20 (2-400) ml, median red blood cell transfusion 1.85 (0.1-8) units and median postoperative hospitalization 10.2 (7-14) days.One case of postoperative pleural effusion was treated by closed drainage of pleural cavity. Conclusions The above CAS is capable of distinctly and accurately delineating the relationship between liver tumor and hepatic vein in children.It may evaluate the feasibility of surgery and optimize operative plans for children with second hilar tumors. Key words: Surgery, computer-assisted; Three-dimensional imaging; Second hepatic portal area; Liver neoplasm; Hepatic vein

As the change of concept of health,the aim of medicine is not only to prolong life and improve the function of organs,but also to help patients to integrate to social life.Previous studies always pay much attention to clinical outcomes ineluding mortality,morbidity,long-term or short-term survival,but patients with liver cancer usually have long disease history and with background diseases such as liver cirrhosis.Traditional liver transplantation and liver resection ale both effective modalities for liver cancer,but liver resection has disadvantages of hish recurrence rate and repeated hepatic artery interventional therapy,and liver transplantation is high-cost.So the health economics and life quality of patients should not be ignored when comparing liver transplantation and liver resection. Key words: Liver neoplasms; Liver transplantation; Hepatectomy; Health economics; Life quality

Objective To investigate the clinical efficacy of laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach. Methods The clinical data of 68 patients who underwent laparoscopic anatomical hepatectomy by Glissonean pedicle transection approach at the Southwest Hospital of Third Military Medical University between March 2009 and December 2013 were retrospectively analyzed. All the patients received intravenous-inhalation general anesthesia. The splitting of liver was carried out after Glissonean pedicles were completely dissected and occluded under the laparoscope according to anatomical structure. The patients with hepatolithiasis underwent intraoperative bile duct exploration and stone removal with T-tube placement based on the conditions of extrahepatic biliary lesions. The fragmented specimens from benign lesions of liver were taken out through a Trocar hole with the diameter of 12mm. The complete specimens from malignancy tumors of liver were taken out through an enlarged Trocar hole or transverse incision at the symphysis pubis. According to the recheck results of benign and malignancy lesions, the patients were followed up by outpatient examination and telephone interview till September 2014. The measurement data with normal distribution were presented as ±s. The survival curve was drawn by Kaplan-Meier method. Results Among the 68 patients, laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach was performed on 64 patients and 4 patients were coverted to open surgery. Laparoscopic anatomical left hemihepatectomy was performed on 30 patients, anatomical right hemihepatectomy on 19 patients, anatomical right posterior lobectomy on 10 patients and anatomical right anterior lobectomy on 9 patients. The mean operation time, volume of intraoperative blood loss, rate of perioperative blood transfusion, time of postoperative gastrointestinal function recovery and duration of hospital stay were (224±117) minutes, (413±349) mL, 5. 9% (4/ 68) , (3. 0±0. 5) days and (8. 0±3. 0) days, respectively. There was no perioperative death, and 6 patients with postoperative complication were cured by symptomatic treatment. The tumor diameter and distance to resection margin in 29 patients with malignancy tumors of liver were (4. 4 ± 1.6) cm and (2. 0±0.9) cm, respectively. The results of pathological examination showed that hepatolithiasis was detected in 22 patients, cavernous hemangioma of liver in 12 patients, hepatic focal nodular hyperplasia in 1 patient, hepatic adenoma in 1 patient, hepatic angiomyolipoma in 1 patient, hepatic multiple cysts in 1 patient, hepatic tuberculosis in 1 patient, hepatocellular carcinoma in 27 patients and cholangiocarcinoma in 2 patients. All the 68 patients were followed up for 6-60 months with a mean time of 24 months. No recurrence and residual stones or lesions in 39 patients with benign lesions of liver were detected during the follow-up. The 1-, 3-, 5-year overall survival rates and tumor-free survival rates in 29 patients with malignant tumors of liver were 92% , 84% , 60% and 83% , 59% , 42% , respectively. Conclusion Laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach is safe and feasible, and is suitable not only for left hemihepatectomy, but also for right hemihepatectomy of high technical specification. Key words: Liver neoplasms; Hepatolithiasis; Laparoscopy; Hepatectomy; Glissonean pedicle

The clinical data were retrospectively analyzed for 21 cases of liver neoplasms undergoing laparoscopic hepatectomy from December 2007 to October 2012. Among 11 cases of borderline hepatocellular carcinoma (HCC) (1.0-9.0 cm), 6 of them were of micro hepatocellular carcinoma (MHCC) with a diameter ≤2 cm. There were 10 cases of borderline hepatic benign tumor, including liver hemangioma (n=7), hepatic adenoma (n=1), liver lymphoma (n=1) and liver focal necrosis (n=1). According to Couinaud's liver segmentation method, neoplasm was located on segment Ⅲ (n=13), segment Ⅳ (n=6), segment Ⅴ (n=1) and segment Ⅵ (n=1). Laparoscopic hepatectomy was successful in all patients. There was neither conversion into open approach nor postoperative complications of bile leakage, air embolism or perioperative mortality, etc. The mean operative duration was (120 ± 30) minutes, average hemorrhagic volume (165±79) ml and normal diet & ambulation at Day 1-2 post-operation. The average postoperative hospitalization stay was (16±10)days and 1-year survival rate 100%. The parameters of leucocyte, liver enzymes, albumin and bilirubin returned to normal at Week 1 post-operation. Once a reasonable surgical indication is selected, laparoscopic resection is both safe and effective for peripheral micro hepatocellular carcinoma. Key words: Liver neoplasms; Laparoscopy