The Clinic Application Of Three-dimensional Technique In The Hepatocellular Carcinoma Surgery

BackgroundOperation is still the first choice of way to treat the hepatocellular carcinoma in modern times. How to get the patients'two dimensional image data of their liver, how to transform these data into three dimensional models and how to make a most suitable operation plan, that was what must be solved by the surgeon before the operation. Tomography lead the one dimensional period into two dimensional period. Tomography changed the shortcomings of one dimensional images with its organs overlap and poorly. However, there were also some problems such as the organs' continuity, intuitive and dynamic display. With the development of the China Digital Virtual Human dataset and multi-CT acquisition technique also computer graphics processing technology,3D software has come out one states by one and been widely used in the clinical work. In the modern times, the foreign 3D software based on the CT scan image data, they can transform these data such as bone, organs, vascular, tumor and so on into three dimensional models, that made the dynamic observation in space come true. However, the most foreign 3D medical software were expensive, what's more, they had no simulation operation instruments, that cannot do simulate operation, so the foreign 3D medical software haven't been widely used. Our study based on the self-developed medical image three-dimensional visualization system(MI-3DVS). With the liver data from live body, two dimensional image data were transformed into three dimensional models rapidly. The tumor inside can be located within the segments that be divided individually according the spread of the portal and hepatic vein inside. Simulate operation and segment volume measuring were done, by doing these a best operation plan can be repeated practice to guide the real surgery. After that, Real operation can feedback the simulate operation. Ultimately, the anatomy digitalization of hepatocellular carcinoma, the procedure of the diagnosis, the simulation of the operation were come true.Object:1. To research the way to quickly and accurately converting the two-dimensional CT of the liver living human sub-millimeter image data into 3D model;2. To study the effects of the normal 3D variation of portal vein on liver section;3. To study the value of 3D technology on guiding liver cancer preoperative planning;4. To study the mutual instruction between real surgery and simulation surgery.Method:1. Materials:(1) 64-slice spiral CT-PHILIPS Brilliance64 (Netherlands PHILIPS company) and image post-processing workstation (PHILIPS Brilliance64 own Mxview spiral CT workstation)(Imaging Center, Zhujiang Hospital, Southern Medical University);(2) HP blade servers (Department of Clinical Digital-Medical Research Center, Southern Medical University), abdominal three-dimensional medical image visualization system (MI-3DVS), virtual simulation surgery equipment system;(3) DICOM viewer; (4) ACDSee10.0 Image conversion software.2. Target: Abdominal CT image data of 100 patients with non-liver disease treated in our department from June 2008 to September 2010 patients; the abdominal CT image data of 45 cases of liver cancer patients, including 34 males and 11 females, aged 13 to 76 years, mean age 45.8 years.3. two-dimensional image data obtained:(1) scan parameters:abdominal CTA, tube voltage of 120KV,300mAs tube current,0.5s per lap, pitch (pitch) 0.984,5mm slice thickness. (2) scan is divided into four phases:precontrast, arterial phase, portal phase, delayed phase, image data which will be cut a thin slice thickness from 5mm to lmm after scaning; (3)Scan Preparation: patients without no diet and water for more than 4 hours, filling the gastrointestinal tract with drinking 300ml of water 20 minutes before scanning, leaving red intravenous catheter tube needle in the right elbow vein with the injection of contrast agent, Ultravist contrast agent for the 370. Enhanced scanning of the contrast agent injection rate of 5ml/s, every scan time is 5s, according to measuring the peak of aortic agent contrast when automatically triggers the arterial phase scan, first scan time is usually 20-25s after the start of injection of agent contrast, the door pulse of the scan time is generally at the 50-55s, the portal venous phase scan immediately start after the delayed phase scan. (4)Data acquisition: In Mxview image post-processing workstation, the four volume of image data transmitted through the line to HP blade servers of our Clinical Medicine Department of the Graduate Center, exported the saved.4. Two-dimensional image data transfer 3D models:two-dimensional image data batch were converted format via DICOM Viewer and processed image adjustment by ACDSeel0.0 image conversion software, then import ed MI-3DVS for fast image segmentation, respectively reconstruction of 3D models, production of the liver, hepatic artery, portal vein, hepatic vein and inferior vena cava, automatic registration was carried through after the completion of each model.5. Preoperative planning:(1) individual liver segments:the method based on semi-manual and identify point. segmentation took the liver blood vessels (portal vein and hepatic veins) of the primary and secondary sub-branch as a basis for variation. According to Couinaud hepatic segment principle, that was the liver vein traveling in hepatic junction, portal vein traveling within the segment, each has an independent blood supply and return path, the segments were divided individually, hepatic tumors then can be accurately located in the liver after being individually divided. (2) volume estimates:3D models and tumor volume were estimated by MI-3DVS volume measurement modules. Through the multi-angle observations of three-dimensional tumor and intrahepatic portal vein, hepatic vein and trunk of inferior vena cava, any combination of observation. In accordance with the location of tumor and delineation of individual segments of liver, virtual pre-anatomical liver resection was carried out, measured resection of the tumor-liver volume and residual liver volume, so that the function of the actual removal of the percentage of liver volume= (removal of tumor-liver volume-tumor volume)/liver volume without tumor, remnant liver volume percentage= 1-the actual removal of the function percentage of the of liver volume (tumor cells do not have the function of liver cells, called void volume; besides the tumor is normal liver cell, called the functional liver volume.)6. The interaction between simulation and the real surgery operation: surgical simulation environment was established by the use of virtual simulation system for surgical instruments, to develop the best surgical removal of individual programs, the virtual surgery exercised the operative procedures in order to guide clinical operation, to avoid intraoperative risk of bleeding may be encountered; after the completion of real operation, the operation can feedback the guidance of simulation surgery to make it further improved and perfect.7. Statistical Methods:The study was the treatment of 3D model and graphic, do not involve statistics.Result:1. The portal vein of 100 cases patients with non-liver-disease can be divided into 5 types, each type has a corresponding individual liver segments:Ⅰtype is the common type, there were 80 cases, the hepatic portal vein separated the left branch and right branch, the left branch then separated the cross section with few branches and the umbilical-segment with small branches, while the right branch separated two branches called anterior and posterior branches, this type of liver can be divided into 8-under section in according with its hepatic portal vein, that was Couinaud segments; typeⅡ, there were 12 cases, the right anterior branch from the trunk of left portal vein and were dry separation, the right posterior branch separate from the main stem, this type of liver segment was the same with the Couinaud segments, but the right liver ofⅤ,Ⅷsegment were narrow, the relations of location is left and right, the blood supply from right anterior branch; typeⅢ, there were 6 cases, hepatic portal vein first divided left branch, and then sent right posterior branch, last the issue of right anterior branch, a separate supply of liver segmentⅤwas right anterior branch, sectionⅤwas long, and left was sectionⅥandⅧ, right posterior branch suppliesⅥ,Ⅶ,Ⅷsection. TypeⅣ, there were 1 case, the portal vein first separated the left portal vein branch and right branch, the end of right branch was like trigeminal, so the right hepatic only be divided into three sections. TypeⅤ, there were 1 case of cavernous transformation of portal vein, hepatic segment can not be divided.2. Two-dimensional CT image data of 45 cases of patients with liver tumors displayed clear: the hepatic artery, portal vein, hepatic vein and inferior vena cava, liver, tumors were clearly visible, the hepatic artery was showed secondary branch, the portal veins and hepatic veins were showed the third branches, the inferior vena cava were clear, the relationship between anatomical location of the tumor were clear.3.45 cases of livers with cancer can be divided into 7 types according to the distribution regions of the intrahepatic portal vein and hepatic vein:21 cases were normal type, the same as Couinaud type,6 cases were non-divided type,11 cases were non-divided of right half liver type,4 case were non-divided of left half liver type,1 case was right liver vein type,1 case was double middle liver vein type, and 1 case was right posterior vein type.4. Operation: among them 39 patients were treated by liver resection operation, the average residual liver volume ratio was 74.3%±16.5%; the vascular and the area which were cut down in the operation were the same as the preoperative 3D model, another 6 cases of patients were treated by TACE because the tumor was so large that can not bear the resection. DSA showed that the tumor were large full filled with vascular just like holding a ball. Fully deposition with lipiodol after injection within the tumor, in according with the feature of primary liver cancer.5. The pathology result of these 39 patients were all hepatocellular carcinoma. There were no acute liver failure, hemorrhage and bile leakage among these 45 cases after operation. All were followed-up for six months after discharged, better survival with or without tumor.Conclusion:1. portal vein is the main blood vessels supplying of the liver, the mutation is common, different types of portal vein, the corresponding liver segment according to its distribution area reflects the individual characteristics, not always the same as Couinaud segments; 2.3D model of the human body image data came from live body, they were the true representation of the liver and intrahepatic blood vessels, truly reflected the original anatomical relationship between tumor and vascular, truly made a living human anatomy digitalize and disease diagnosis automatic;3.3D technology made individual liver segments, volume measurement and the choice of preoperative surgical planning, surgical simulation programs helped to develop and conduct exercises, truly achieved a visual operation simulation;4. According to the simulation for surgical laparotomy, then according to the results to determine the actual surgical exploration, simulation operation in full compliance with the actual surgery,3D technology have a non-invasive, rapid and accurate guidance.