| IntroductionGenerally, we could perform conventional CT examination by the patients who with liver tumor, and get CT data information, however, when the doctors make a diagnosis of these diseases with the information got from the CT images, these require physician or surgeon to dependent on their subjective experience in mind, and then convert two-dimensional (2D) CT images to (three-dimensional) 3D images. After the above processing,We could have the knowledge of the spatial relationships between the liver tumor and hepatic vessels. But the personal experience was often unreliable, deviations may occur, sometimes. What’s more,3D reconstruction by radiology physician on the CT workstation, which always mono-modality, and cannot freely combine and observe their relationship between liver tumor and hepatic vascular structure, and these 3D images were often unable to meet demand by surgeon, liver organ have complex vascular structure, often accompanied by vascular variations, it is very important for the surgeon to make clear the orientation of the liver tumors and the spatial relationships between the tumor and hepatic vascular system. Furthermore, the preoperative visualization of the liver by the 3D reconstruction software (such as Medical Image Three-Dimensional Visualization System MI-3DVS), but observed liver 3D image models by computer 2D monitor, which responsed the sense of spatial distance was still limited. Along with the advancement of science and technology, and now 3D printing physical models have been used in clinical medicine, such as head and neck surgery, facial plastic surgery, orthopedic, prosthetic implants, and other clinical medicine fields.3D printed models can reflect the spatial relationships of lesions and surrounding organs accurately, which was mainly applied to preoperative planning, virtual surgery, as well as guidance of surgical intraoperative operation in real time. Some researchs showed, such as this two study, one study that applied liver 3D printed models in assistance with surgery in small liver tumor, completed liver resection successfully, and obtained surgical margin; the other study that applied 3D printed-liver for living donor liver transplantation, completed donor hepatectomy and actual explanted recipient total liver successfully. And in past two decades years,2D Laparoscopy in liver resection played a important role, but 2D Laparoscopy on space depth perception missing, or shortcomings, which has some defects for complex laparoscopic tasks such as suturing and knot tying, that may have a disavantage of intraoperative bleeding control. whether could control surgical intraoperative bleeding or not, was a key factors for laparoscopic liver resection. thus it’s this disavantage that probably limited development of conventional liver resection.3D Laparoscopy was born in demand of the times, which improved depth perception, HD resolution and precise positioning, experimental and clinical studies have shown that 3D laparoscopy in laparoscopic surgery can reduce operating time, reduce number of repetitions, and reduce number of errors. And help for complex laparoscopic operation such as suturing and knot tying.Fang et al applied 3D visualization technology combined with 3D laparoscopy in 16 patients who with hepatobiliary diseases, achieved digital minimally invasive surgery precisely. Makuuchi et al research showed that malignant tumors of the liver, mainly along the portal vein of liver metastasis, through removal the hepatic segments of liver tumor belongs, could get better prognosis, reduced risk of metastasis and recurrence after surgery. And in recent years, anatomical liver resection was more and more accepted by surgeons, which performed en bloc resection,that removed vascular topological portal vein of segmentectomy, subsegmentectomy or combined several segmentectomy completely.reserved anatomical structure integirty of the future remant liver,to avoid postoperative remant liver congition and liver failure. Along with the development of digital medical technology, some techniques are available, minimally invasive surgery has been more accepted by patients and surgeons. In order to achieve digital anatomy, diagnostic procedures,’surgical 3D visualization, We would like to explore the value with the application of 3D visualization,3D printing, and 3D laparoscopic techniques (were short for 3-3D techniques) in diagnosis and surgical treatment for liver tumors.Objective1) Collected thin-slice CT scanning data of 22 patients who were liver tumors, to construct three dimensional visualization models.2) Be familiar with 3D visualization models, identified distribution of hepatic vessels, and then classified and statistic analysis.3) Liver segmentation was performed by 3D visualization in MI-3DVS, ascertained the location of liver tumor, and then make the virtual liver resection, calculate the volume of virtual resection, the volume of virtual liver remnant, the ratio of virtual liver remnant volume.4) Performed preoperative planning, intraoperative assessment and postoperative evaluation by 3D visualization.5) Printed 3D liver physical models and observed them, and used them for preoperative planning and intraoperative guidance procedure.6) Application of 3D visualization,3D printing, and 3D laparoscopy techniques (3-3D techniques) performed anatomical hepatectomy, to explore their clinical value.1. Materials1.1 Clinical dataFrom December 2013 to January 2015 in our department of hepatobiliary surgery(Ⅰ),Zhujiang hospital, Southern Medical University, clinical data of 22 patients with liver tumors was collected.Inclusion criteria:(1) Based on the imaging diagnosis of liver lesions, including liver benign lesions and malignant lesions, benign disease including symptoms of cavernous Hemangioma, symptomatic Focal nodular hyperplasia, adenoma, liver cancer including primary liver cancer, secondary liver cancer and other malignant liver tumor; (2) the function of heart and lung is good,liver function was Child-Pugh A to B; (3) Competence by abdominal pressure.Exclusion criteria:(1) liver function poor, Child-Pugh C; (2) the function of heart and lung is poor, cannot tolerance gas abdominal; (3) the relationship of the liver lesions and portahepatis is intensity, can not exposed or divided these anatomic structure, or needs biliary, digest reconstruction, for example hilar cholangiocarcinoma; (4) the lesions were close to secondary porta of liver, and inferior vena cava; (5) Non-parenchymal lesions or Inflammatory lesions, such as hepatolithiasis, hepatic cyst ,liver abscess and so on. According to the above inclusion and exclusion criteria, there were 22 cases included,14 males,8 females; mean age 52 ± 13 years (28-70 years). United States Association of anesthesiologist anesthesia graded ASA assessment grade I was 18 cases; grade II was 4 cases. All patients signed an informed consent. This study was approved by the Ethics Committee of the Zhujiang hospital, Southern Medical University.1.2 Instruments and equipment1.2.1 3D reconstruction of instrument and equipment(1)256 slice spiral CT scanner (CT PHILIPS Brilliance 256, Dutch), Detector combination (0.625mmx256);(2)Double tube high pressure syringe and contrast agents (Lopamiro in a dose of 370 mg I/ml);(3)The self-attached Mxview workstation for post processing of the images in CT scanner;(4)Medical Image Three-Dimensional Visualization System (MI-3DVS);(5)High configuration 1 computers, install MI-3DVS.2.2 3D printing apparatus and equipment(1) The CT scanner:256-slice helical CT (Philips Brilliance, Dutch);(2) Medical image three dimensional visualization system (MI-3DVS);(3) Portable computer(4) Software:Geomagic Studio 2013,Raindrop Geomagic software company, United States; analysis of Geomagic Quaify 2013,Raindrop Geomagic software company, United States; rapid prototyping software Magic 4.0, Materialise company, Belgium;(5) Printed materials:high-performance composite materials ZP150,Z Corporation, United States imports curing glue Z-bond 90,3D system, United States;(6) 3D printer:Spectrum ZTM 510 3D printer, Z Corporation, United States. 2.3 Laparoscopic liver resection apparatus and equipments(1) 3D laparoscopic equipment:Germany KARL STORZ 3D HD camera system, United States 32-inch Sony HD monitors;(2) Harmonic Scalpel,Ultracision, Ethicon;(3) Endo-GIA endoscopic linear cutter closed, Endo Retract(Covidien);(4) Ligasure, Valleylab company, United States;(5) laparoscopic General instruments2 Methods2.1 Abdominal CT scan on 256-slice helical CT (Philips Brilliance, Netherlands)-enhanced, obtained thin -slice CT DICOM data.2.2 Data acquisition and storageThe CT data obtained by the 256-slice helical CT in the image center of zhujiang hospital., which were dealed with into thin-slice (0.625～1.5mm). These process were finished though internal network system transmission with the HP blade type sever coexist dise in the Digital medical clinical center of Southern Medical University.2.3 3D reconstructionThe several phases thin-slice CT data were imported to the MI-3DVS. And then, Proofing, registration and 3D reconstruction. The 3D images were handled with smoothing and denoising processing in the graphics software.2.3.1 Observed the course and distribution of hepatic vessels in MI-3DVS, and performed hepatic vascular types by approved classifications.2.3.2 The classification of hepatic arteryAccording to the 1966 Michels classification, divided into 10 types.2.3.3 The classification of portal veinAccording to the 1996 Cheng’s classification, divided into 7 types.2.3.4 The classification of hepatic veinHepatic vein was classified by Nakamura.1) According to left hepatic vein (LHV) and hepatic vein (MHV) flow into the inferior vena cava (IVC) pattern was performed two types.2) The classification of right hepatic vein (RHV):According to combine with right hepatic vein, right inferior hepatic vein or middle right hepatic vein, which RHV was classified into three types.3) Couinand’s IV segment hepatic vein was classified into three types 2.3.5 Division of Couinand’s segment, virtual liver resection and measurement of liver volume by MI-3DVS.According to Couinaud’s theory, division the liver for 8-9 segments, realized the lesions belongs to which segments,performed virtual liver resection, calculation of virtual liver volume,residual liver volume, and residual liver volume ratio.2.43D print physical models3D printed models included four steps:3D image reconstruction, digital preparation,3D printing, and postprinting finishing work..2.5 Application of 3D visualization,3D printing and 3D laparoscopy performed anatomical liver resection procedureApplication of Germany KARL STORZ 3D HD camera system and 32-inch Sony HD monitors, combined with3D visualization,3D printing and 3D laparoscopy performed anatomical hepatectomy.Anatomical liver resection refers to parenchymal preserving resections of portal territories including sectionectomy, segmentectomy, and subsegmentectomy.The definition of anatomical hepatectomy is the anatomical structure and physiological effect of residual liver parenchyma remain functional integrity when completed the hepatectomy, assured the remnant liver volume has adequate vascular inflow and outflow. The anatomical hepatectomy include anatomical regular hepatectomy and irregular hepatectomy.2.5.13D laparoscopic anatomical liver resection general procedures, as follows:1) placed in a appropriate (supine) position; 2) determines puncture points and established trocar placement; 3) for 3D laparoscopic exploration, used 3D visualization of image models, and 3D printed models ascertain tumor location, defined and performed liver resection procedure; 4) 3D visualization, and 3D printed model guide 3D laparoscopic anatomical hilar dissection and selective hepatic vascular occlusion; 5) liver ligament of mobilization; 6) liver parenchymal division; 7) processing the liver section of stump; 8) Specimen removal; 9) placed drainage tube.2.5.23D laparoscopic anatomical liver resection about Specific which couinaud’s segments procedures1) 3D laparoscopic anatomical right hemihepatectomy; 2) 3D laparoscopic anatomical right posterior sectionectomy; 3) 3D laparoscopic anatomical left hemihepatectomy; 4) 3D laparoscopic anatomical left lateral sectionectomy; 5) 3D laparoscopic anatomical Couinand’s V orVI segmentectomy; 6) 3D laparoscopic anatomical Couinand’s Ⅷ segmentectomy; 7) 3D laparoscopic anatomical Couinand’s IVb subsegmentectomy.2.6 Observed variablesLaboratory examination included Hb, PLT, PT, AST, ALT, TBIL, and ALB; and operation methods, operation time, intraoperative blood loss, postoperative hospital stay, total length stay, the rate of intraoperative blood transfusion, postoperative morbidity and mortality; and the volume of virtual liver resection, the volume of remant liver and the volume of actual liver resection.2.7 Postoperative follow-upPostoperative regular follow-up by liver function in 1-3 months after the operation, and CT scanning and 3D reconstruction to evaluate postprognosis.2.8 Statistical analysisStatistical analysis was performed using SPSS 19.0 for Windows. Continuous data were presented as mean ± standard deviation(Mean±SD), while categorical variables were presented as n (%). For statistical analysis, the volume of virtual liver resection and the volume of actual liver resection were compared by paired t-tests, and correlation coefficients by Pearson were calculated. In all cases, statistical significance was defined as P< 0.05.3 Results3.1 Results of 3D reconstructionIt’s quickly completed the CT data segmentation, registration and reconstruction by MI-3DVS. And the liver of 3D visualization could be displayed hepatic vessels and liver tumor structure clearly.3.1.1 Liver, hepatic vessels and liver tumor, Among of their space relationshipsObserved the image of 3D visualization, which could clearly identified the location, size, shape, number of liver tumor and hepatic vascular distribution, travel and their variations, and could reflected the liver tumors and hepatic vascular anatomical structure very well; what’s more, we could measure the distance between liver tumors and vessels as required.3.1.2 The classification of hepatic arteryBy the classifications of Michels:type I was 86.4%(19/22), type II was 9.1% (2/22), type VIII was 4.5%(1/22), and no other Variations. Hepatic artery variation was 13.7% (3/22).3.2.2 The classification of portal veinThe classification By Cheng:type I was 77.3% (17/22), type II was 9.1% (2/22), type III was 9.1% (2/22), type IV was 4.5%(1/22), none of type V,VI and VII variations.3.1.3 The classification of hepatic vein1)LHV and RHV drainge into IVCLHV and RHV have common trunk drainge into IVC 86.4%(19/22), LHV, RHV independently drainge into the IVC 13.6% (3/22).2) The classification of right hepatic veinType I was 45.5%(10/22), type Ⅱ was 31.8% (7/22), type Ⅲ was 22.7% (5/22).3) The classification of Couinaud’s IV hepatic vein (according to Couinaud’s IV segment hepatic vein which flow into)Type I was 59.1% (13/22), type Ⅱ was 9.1% (2/22), and type Ⅲ was 31.8%(7/22).3.1.4 Liver tumor located in Couinaud’s segmentsAccording to Couinaud’s principle,22 cases of liver tumor located in which Gouinaud’s segments, as follow:Located in Couinaud’s Ⅳ, Ⅵ, Ⅶ and VIII segments were 3 cases; Located in couinaud’s Ⅳ,Ⅵ and VIII segments was 1 case; Located in the couinaud’s VI and VII segments were 2 cases; in the couinaud’s Ⅱ and Ⅲ segments were 5 cases; in the couinaud’s Ⅱ segment were 2 cases; in Couinand’s IV segment were 2 cases; in Couinand’s V segment was 1 case; in Couinand’s VI segment were 3 cases; Couinand’s Ⅶ segment were 2 cases; Couinand’s Ⅷ segments were 2 cases.3.1.5 Volume measurement by MI-3DVS system, as follow:The mean of functional liver volume were 1248±106ml; The mean of liver tumors volume were 137± 123ml; The mean volume of virtual liver resection was 490±228ml; The mean of residual liver volume was 885±139ml; the ratio of residual liver volume and functional liver volume was 0.71± 0.11 (range 0.39～0.86) 。3.2 Results of 3D printingPerforming 3D printed-models with the ratio of one to one 3D reconstruction models, which was created consistently in high-fidelity 3D physical models. Before the operation can be observed clearly spatial relationships among liver tumors and hepatic vessels.3.3 Results3.3.1 Perioperative period result statisticsAmong of 22 cases, the average time of dissect the hepatic hilum was (42 ±10) min, the average operation time was (186 ± 92) min, the average amount of bleeding was (284± 286) ml, the mean postoperative hospital stay was (8.6 ±3.7) d. The intraoperative transfusion rate was 18.2% (4/22), included pure laparoscopic hepactectomy and conversion were 2 and 2 cases, respectively. And the result of postoperative laboratory tests in table 1.20 cases completed in 3D laparoscopic anatomical liver resection successfully, which included right hemihepatectomy were 4 cases, right posterior sectionectomy were 2 cases, left hemihepatectomy were 2 cases, left lateral sectionectomy were 5 cases, hepatic segmentectomy or subsegmentectomy were 7 cases. The average operation time was (175 ± 89) min, the mean of intraoperative bleeding loss was (212 ± 174) ml and the mean postoperative hospital stay was (8.0 ± 3.2) d. Laparoscopic intraoperative blood transfusion rate was 10% (2/20).Two cases conversion to open surgery, which included one case of right posterior sectionectomy, one case of Couninand’s Ⅷ segmentectomy, for anatomical location limited to exposed, and intraoperative bleeding. the average operation time was (290 ± 42) min, the mean intraoperative blood loss was (1000 ± 141) ml and the mean postoperative hospital stay (15.1 ± 2.6) d.Generally, The patient of pure laparoscopic surgery could go around after operation 2-3 days, could removed the gastrointestinal decompression tube after 2-4 days, and removed the drainage tube after operation 3-7 days. 3.3.2 Comparison of virtual resection volume and the actual liver volumeThe mean of virtual resection volume (490±228) ml, the mean of actual removal (491±192) ml, paired t test (t=-0.016, P>0.05), the difference was not statistically significant, and Pearson correlation analized(r=0.979, P＜0.001), which displayed virtual resection volume and the actual liver volume was correlated highly.3.3.3 Pathological conditions11 cases of hepatocellular carcinoma,2 cases of mixed hepatocellular-cholangiocarcinorna,2 cases of metastatic adenocarcinoma, one case of sarcomatous hepatocellular carcinoma,6 cases of cavernous hepatic Hemangioma,2 cases of focal nodular hyperplasia.14 cases of malignant tumor resection margins were achieved negative surgical margins (R0).3.3.4 Postoperative complicationsThree cases with the complication of pleural effusion, one case of ascites, one cases of bileleakage, and the other of 17 patients was not postoperative complications. No intraoperative or postoperative deaths occurred.3.3.5 The postoperative follow-up resultsAll of 22 patients underwent follow-up one to eleven months, median follow-up time was five month. Six Months after operation,which one case was liver metastasis accompanied by tumor thrombi in portal vein.4. Analysis of typical cases.5. Conclusions1) 3D visualization technique, which could facilitate to the risk of preoperative evaluation, intraoperative assessment and postoperative evaluation.2) 3D printing models, which could facilitate to identify and ascertain critical anatomical structure, and manage major vascular structure of intraoperative divession, indirectly navigate intraoperative operation and en bloc resection of the hepatic tumor in real time, which improved precise surgical procedure.3) 3D laparoscopy,which could be helpful to dissect the hepatic hilum, process intraoperative complex task,be suitable for performing anatomical hepatectomy, especially for major hepatectomy.In brief, Combined applications of 3D visualization,3D printing and 3D laparoscopy techniques, and complemented their advantages, which could contribute to achieving of minimally invasive surgery and precision in liver surgery. |
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