Application Of “Three Lines And One Plane” As Anatomic Landmarks In Laparoscopic Surgery For Extrahepatic Biliary Diseases

Part ?:Application of“three lines and one plane”as anatomic landmarks in laparoscopic surgery for extrahepatic biliary diseasesBackground : Based on previous preoperative imaging data and intraoperative observation of biliary tract patients,we proposed “three lines and one plane” as landmarks in laparoscopic surgery for extrahepatic biliary diseases.That is,upper margin curve of the first part of duodenum(A-line);the arc incisure curve of the hepatic pedicle of the right posterior lobe(B line);The line connect the two points(C line),one point is the middle of " the base plane of segment ?a",the other point is the middle of the A line;and the plane of the hilar plate(D plane).They were found to locate at the periphery of the operation area,similar to sailing away from the center of the storm,and less disturbed by extrahepatic inflammatory adhesion and anatomical variation.Objective : 1.Analyze conversion rate and complications of LC and/or LCBDE patients in this group,evaluate the safety and feasibility of applying " three lines and one plane " landmarks of extrahepatic biliary tract and establishing a set of surgical procedures based on " three lines and one plane " anatomical markers in LC and/or LCBDE.2.Compare "three lines and one plane" with classic landmarks such as Rouviere sulcus,Rouviere sulcus plane,cystic lymph nodes,the right margin of segment ?,evaluation the application value of "three lines and one plane" landmarkers in complex and anatomical variation cases.Methods: From January 2016 to October 2018,1407 cases of laparoscopic cholecystectomy and 238 cases of laparoscopic common bile duct exploration consecutively performed in our treatment team of General Hepatobiliary and pancreatic surgery of the Second Affiliated Hospital of Anhui Medical University.“Three lines and one plane” were used as anatomical landmarks for extrahepatic bile ducts during operation in all patients.The informations of diagnosis,treatment and postoperative complications of the patients were collected from medical records,surgical records,and nursing records through the hospital information system.We set up EXCEL table with the retrieved and sorted data.Result:All the patients had a smoothly recovery without severe complications,such as vascular,intestinal injury.No patient died after operation.In the LC group,1case(0.06%,1/1645)presented Luschka duct bile leakage and recovered after puncture catheter drainage.No recurrent biloma in the gallbladder bed area was found in the follow-up 12 months after catheter extraction.In the whole group,8 patients were converted to laparotomy(0.49%,1/1645,including 4 patients in LC group and 4 patients in LCBDE group).In LC group,1 case of Mirizzi syndrome type ? who underwent subtotal cholecystectomy and stump suture was followed up for more than 9 months,no stone formation in cystic duct remnant.Other postoperative complications included 1 case accepted ERCP therapy in the LC group who had secondary common bile duct stone.In LCBDE group,2 cases of Mirizzi syndrome type? who placed T-tube drainage for more than six months,no recurrent common bile duct stone and biliary stenosis were found by angiography and choledochoscope.After CBD incision and exploration,primary suture was performed in 107 cases(45.0%),T tube drainage in 131 cases.Postoperative mild bile leakage occurred in 4 cases(4/238,1.7%),3 cases in T-tube group,and 1 case in primary suture group,all of them were cured by abdominal drainage.One case of common bile duct stone recurrence was found 3 months after primary suture,and was cured by ERCP.The rest of the patients recovered uneventfully and no recurrence of stones or cholangitis occurred during follow-up.Conclusion : Anatomical landmarks of “three lines and one plane” is benefit in helping surgeons to build a three-dimensional(3D)anatomical construction,and avoiding the operative injury of the bile duct,and vessels.In addition,it can not only be applied in gallbladder surgery,but also in common bile duct surgery and biliary reoperation,which is worth popularizing and applying.Part ?: The finding of the anatomical landmarkers of extrahepatic biliary tract combined with CT,MRCP and intraoperative imagesBackground:(1)Rouviere's sulcus is the most classic landmark in LC.However,at present,its morphology,course,and whether there is hepatic pedicle in sulcus,are all observed by naked eyes,and there is a lack of studies on the morphology,direction and composition of Glisson in RS sulcus from imaging data before operation.(2)we proposed “three lines and one plane” as landmarks in laparoscopic surgery for extrahepatic biliary diseases.C line is the connection between two points,one point is the middle of " the base plane of segment ?a",the relationship between the point and the location of the hepatic duct lack of further research on imaging or anatomy.Obejective:(1).To evaluate the recognition of Rouviere's sulcus by CT;(2).To evaluate the relationship between the upper starting point of line C proposed by us and hepatic duct by MRCP,and its guiding significance for surgery.Method : Retrospective analysis was performed on 48 patients with LC and LC+LCBDE in our hospital from May 2018 to January 2019,who had clear surgical videos and complete hepatobiliary CT(non-contrast or contrast)and/or MRCP imaging data.The clinic informations and corresponding video informations were procured through the hospital information system(HIS).Access to patient CT and/or MRCP images via the hospital image archiving and communication system(PACS)link.With the cooperation of hepatobiliary specialists in our team and senior radiologists in film reading,the preoperative MRCP/CT data were compared with the intraoperative video data by blind observation.Result:Finally,48 patients with LC and LC+LCBDE were included,among which 11 patients only had CT data(non-contrast or contrast),5 patients only had MRCP,and 32 patients were treated with CT and MRCP at the same time.There were 18 males and 30 females.Age 17-87,average age 52.75.(1)for the 43 cases with CT data,the RS sulcus were divided into three types in video: open type(33,76.7%),fused type(3,7.0%),and absent type(7,16.3%).RS sulcus was divided into RS sulcus(34 cases,79.1%)and no RS sulcus(9 cases,20.9%)on CT according to whether there was a hiatus in the hepatic margin of the right liver near the first hilum of the right liver extending downward from the opening of the right hepatic pedicle and the right posterior hepatic pedicle.According to the gold standard observed by the naked eyes,the sensitivity and specificity of CT were 94.3 %(33/ 35)and 87.5%(7 / 8),respectively.The positive predictive value was 97.1%(33/34),and the negative predictive value was77.8%(7 / 9).The accuracy rate was 93.0%(40/43);Analysis of the consistency between the results of naked eyes and CT images in 43 patients: Youden index 81.8%,kappa =0.78,P=0.000.In 43 patients,the results of naked eyes and CT images of RS sulcus showed a high degree of consistency(substantial).The CT images of 34 patients with RS sulcus were further analyzed.The proximal portal area of RS sulcus was the trunk of right posterior hepatic pedicle in 30 patients.Three patients had two right posterior trunk,one of which was in RS sulcus.In 2 cases,6th hepatic pedicle branches were imported into the sulcus alone.MRCP data of 37 cases showed the angle of extrahepatic bile duct tree in R-L position image were 27°to 78 °,average 60 °,mainly in 50-70°range.In T2-weighted images,we compare the hepatic duct and the left and the convergence of left and right hepatic duct with the midpoint of "the base plane of segment ?a" through continuous scanning.According to the relationship between them,we divided them into three types: type 1: the midpoint of "the base plane of segment ?a" corresponding with the midpoint of hepatic duct and the convergence of left and right hepatic duct.This type accounted for 12/37,32.4 %;Type 2: the midpoint of hepatic duct corresponding with midpoint of "the base plane of segment ?a",but the convergence of left and right hepatic duct of obvious deviation to the right side of the midpoint of "the base plane of segment ?a"(near the gallbladder bed side).This type accounted for 22/37(59.5%).Type 3: the midpoint of hepatic duct and the convergence of left and right hepatic duct are on the right of the midpoint of "the base plane of segment ?a",this type in 3 cases,accounting for 8.1%.Conclusion:(1)RS sulcus is a hepatic fissure extending with the B line.Intraoperative judgment can be made according to the principle of "continuation with B-line ".This study indicate that the RS sulcus could be judged by CT images by whether there is a hiatus in the hepatic margin of the right liver near the first porta hepatis extending downward from the opening of the right hepatic pedicle and the right posterior hepatic pedicle.And the composition of the right posterior hepatic pedicle in the RS sulcus can be observed by CT images,especially contrast-enhanced CT.(2)the extrahepatic bile duct slope downward and right-to-left from the convergence of left and right hepatic duct to the common bile duct.MRCP imaging results are basically in agreement with clinical observation for the midpoint of "the base plane of segment ?a" corresponding with the midpoint of hepatic duct The C line principle has guiding significance in clinic.