Three-dimensional morphometric analysis for hepatectomy of centrally located hepatocellular carcinoma: A pilot study

3-D reconstruction in liver surgery: a systematic review

BACKGROUND

Three-dimensional reconstruction of the liver offers several advantages to the surgeon before and during liver resection. This review discusses the factors behind the use of liver 3-D reconstruction.

METHODS

Systematic electronic search, according to PRISMA criteria, was performed. A literature search of scientific papers was performed until October 2023. Articles were chosen based on reference to 3-D liver reconstruction and their use in liver surgery. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies.

RESULTS

The research included 47 articles and 7724 patients were analyzed. Preoperative planning was performed with 3-D liver reconstruction in the 87.2% of the studies. Most of preoperative 3-D liver reconstructions were performed in the planning of complex or major hepatectomies. Complex hepatectomies were performed in 64.3% patients. The 55.3% of the studies reported an improved navigation and accuracy during liver resection. Four studies (8.6%) on living donor liver transplant (LDLT) concluded that 3-D liver reconstruction is useful for graft selection and vascular preservation. Nine papers (19.1%) reported an accurate measurement of future liver remnant.

CONCLUSION

Liver 3-D reconstruction helps surgeons in the planning of liver surgery, especially in liver graft and complex liver resections, increasing the accuracy of the surgical resection.

Postoperative radiotherapy following null-margin hepatectomy in patients with hepatocellular carcinoma adhering to the major vessels: A propensity score-matched survival analysis cohort study

Background & Aims

This study aims to analyze the prognosis of null-margin (≤1.0 mm) hepatectomy (NH) in patients with hepatocellular carcinoma (HCC) adhering to the major vessels and explore the value of postoperative radiotherapy (RT) in these patients.

Methods

HCC patients who underwent null-margin or wide-margin (≥1.0 cm) hepatectomy (WH) by our team from January 2008 to March 2016 were recruited and analyzed retrospectively. The patients were divided into the NH, NH + RT, and WH groups. Propensity score matching (PSM) was performed to balance baseline characteristics.

Results

A total of 357 patients were recruited. Of these, 84, 49, and 224 patients were given NH alone, NH plus RT, and WH, respectively. After PSM, the 5-year overall survival (OS) and disease-free survival (DFS) rates of the NH group were significantly worse than those of the WH group (51.5 % vs. 71.4 %, P = 0.003; 32.2 % vs. 50.9 %, P = 0.005). The OS and DFS rates of the NH + RT group were significantly higher than those of the NH group (75.6 % vs. 56.1 %, P = 0.012; 46.6 % vs. 30.2 %, P = 0.015) and similar to those of the WH group (75.6 % vs. 75.1 %, P = 0.354; 46.6 % vs. 56.6 %, P = 0.717). In addition, patients in the NH + RT group experienced significantly lower early (P = 0.023) and intrahepatic (P = 0.015) recurrences than those in the NH group.

Conclusions

Patients with HCC adhering to the major vessels who underwent NH alone had a poorer prognosis, and the addition of RT to NH provide a significant survival benefit for these patients, which may yield outcomes comparable to the efficacy of WH.

Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience

INTRODUCTION

Virtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy.

METHODS

Patients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured.

RESULTS

Twenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively).

CONCLUSIONS

Virtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

A Bibliometric Analysis of the Role of 3D Technology in Liver Cancer Resection

BACKGROUND

Liver cancer resection is an effective but complex way to treat liver cancer, and complex anatomy is one of the reasons for the difficulty of surgery. The use of 3D technology can help surgeons cope with this dilemma. This article intends to conduct a bibliometric analysis of the role of 3D technology in liver cancer resection.

METHODS

(TS = (3D) OR TS = (three-dimensional)) AND (TS = (((hepatic) OR (liver)) AND ((cancer) OR (tumor) OR (neoplasm)))) AND (TS = (excision) OR TS = (resection)) was used as a search strategy for data collection in the Web of Science (WoS) Core Collection. CiteSpace, Carrot2 and Microsoft Office Excel were used for data analysis.

RESULTS

Three hundred and eighty-eight relevant articles were obtained. Their annual and journal distribution maps were produced. Countries/regions and institutions collaboration, author collaboration, references co-citations and their clusters and keywords co-occurrences and their clusters were constructed. Carrot2 cluster analysis was performed.

CONCLUSIONS

There was an overall upward trend in the number of publications. China's contribution was greater, and the USA had greater influence. Southern Med Univ was the most influential institution. However, the cooperation between institutions still needs to be further strengthened. Surgical Endoscopy and Other Interventional Techniques was the most published journal. Couinaud C and Soyer P were the authors with the highest citations and centrality, respectively. "Liver planning software accurately predicts postoperative liver volume and measures early regeneration" was the most influential article. 3D printing, 3D CT and 3D reconstruction may be the mainstream of current research, and augmented reality (AR) may be a future hot spot.

Methods and Applications of 3D Patient-Specific Virtual Reconstructions in Surgery

3D modelling has been highlighted as one of the key digital technologies likely to impact surgical practice in the next decade. 3D virtual models are reconstructed using traditional 2D imaging data through either direct volume or indirect surface rendering. One of the principal benefits of 3D visualisation in surgery relates to improved anatomical understanding-particularly in cases involving highly variable complex structures or where precision is required.Workflows begin with imaging segmentation which is a key step in 3D reconstruction and is defined as the process of identifying and delineating structures of interest. Fully automated segmentation will be essential if 3D visualisation is to be feasibly incorporated into routine clinical workflows; however, most algorithmic solutions remain incomplete. 3D models must undergo a range of processing steps prior to visualisation, which typically include smoothing, decimation and colourization. Models used for illustrative purposes may undergo more advanced processing such as UV unwrapping, retopology and PBR texture mapping.Clinical applications are wide ranging and vary significantly between specialities. Beyond pure anatomical visualisation, 3D modelling offers new methods of interacting with imaging data; enabling patient-specific simulations/rehearsal, Computer-Aided Design (CAD) of custom implants/cutting guides and serves as the substrate for augmented reality (AR) enhanced navigation.3D may enable faster, safer surgery with reduced errors and complications, ultimately resulting in improved patient outcomes. However, the relative effectiveness of 3D visualisation remains poorly understood. Future research is needed to not only define the ideal application, specific user and optimal interface/platform for interacting with models but also identify means by which we can systematically evaluate the efficacy of 3D modelling in surgery.

Modified median hepatic fissure approach for resection of liver tumours located in the angle between the root of the middle and right hepatic veins

Background

Liver tumours between the root angle of the middle and right hepatic veins are a special type of liver segment VIII tumour. In this study, we designed a modified median hepatic fissure approach to remove these tumours. The safety and effectiveness of the approach were evaluated.

Materials and methods

From April 2015 to November 2019, 11 patients with liver tumours between the angle of the middle and right hepatic veins underwent this modified median hepatic fissure approach. We retrospectively analysed data from the perioperative periods of these 11 patients, including general condition, operation time, intraoperative bleeding, and postoperative complications. Disease-free survival and overall survival were assessed.

Results

Of the 11 patients, 9 patients had primary hepatocellular carcinoma and 2 had colorectal liver metastases. The average intraoperative blood loss was 285 mL (150–450 mL). Two patients developed postoperative bile leakage, but there were no significant serious complications, such as intraabdominal bleeding and liver failure, in any of the patients. The liver function returned to the normal range on the 5th day after surgery. Of the 11 patients, 5 have survived for more than 3 years (45.5%), and 4 have been disease-free for more than 3 years (36.3%).

Conclusions

For liver tumours between the root angle of the middle and right hepatic veins, the modified median hepatic fissure approach is a safe and feasible method.

Clinical application of a three-dimensional reconstruction technique for complex liver cancer resection

OBJECTIVE

To explore the utility of three-dimensional (3D) visualization technology in liver resection for patients with complex liver cancer.

METHODS

In this retrospective cohort study, we collected and analyzed clinic pathological data from 105 patients who underwent complicated liver cancer resection at the authors' unit between January 2014 and June 2019. Observation indicators included general demographic information, operative time, intraoperative blood loss, blood transfusion volume, postoperative liver function, complication rate, hospital stay, and in-hospital mortality.

RESULTS

Compared with the complex liver cancer control group, operative time (257.1  ±  63.4 min versus [vs] 326.6  ±  78.3 min; P < 0.001), intraoperative blood loss (256.4  ±  159.1 mL vs 436.1  ±  177.3 mL; P < 0.001), blood transfusion volume (213.3  ±  185.2 mL vs 401.6  ±  211.2 mL; P < 0.001), and length of hospital stay (9.7  ±  3.1 days vs 11.9  ±  3.3 days; P = 0.001) were significantly reduced in the complex liver cancer reconstruction group. Although there was no statistical difference in total postoperative complication rate between the two groups, the incidence of serious postoperative complications in the reconstruction group was significantly lower than that in the control group (3/54 [5.6%] vs 10/51 [19.6%], respectively; P = 0.038). Regarding laboratory investigations, the time to recovery of liver function in the complex liver cancer reconstruction group was shorter than that in the complex liver cancer control group.

CONCLUSION

The use of 3D visualization technology was highly influential in formulating meticulous, individualized surgical strategies for complex liver cancer liver resection with safety and reduced perioperative risk.

The Application of Preoperative Three-Dimensional Reconstruction Visualization Digital Technology in the Surgical Treatment of Hepatic Echinococcosis in Tibet

Objective: The present study aims to explore the application value of three-dimensional (3D) reconstruction technology in the preoperative evaluation of patients with complicated hepatic echinococcosis in Tibet.

Methods: A total of 200 patients with complicated hepatic echinococcosis, admitted to our hospital between May 2019 and December 2020, who underwent radical hepatectomy, were enrolled in the present study. The patients were randomly divided into a preoperative computer tomography group and a preoperative 3D reconstruction group. According to the imaging results, a surgical plan was formulated. A comparison was made between the two groups of the coincidence rate of the surgical plan and intraoperative and postoperative complications.

Results: The patients with hepatic echinococcosis who underwent 3D visualization reconstruction before surgery had a high compliance rate with the surgical plans and the operating time, the number of cases with blood flow blockage, the blood flow blockage time, intraoperative hemorrhage, and postoperative biliary fistulas were significantly lower.

Conclusion: The application of preoperative 3D visualization reconstruction in patients with complicated hepatic echinococcosis in Tibet could effectively improve surgical safety.

[Systematic review of current trends in preoperative planning of surgery for liver tumors]

The purpose of the study was a systematic review of current trends in preoperative planning of surgery for liver tumors. These data will be valuable to determine the advantages and disadvantages of 3D modeling, augmented reality technology and 3D printing in preoperative planning of surgery for focal liver lesions.

Congenital biliary dilatation in the era of laparoscopic surgery, focusing on the high incidence of anatomical variations of the right hepatic artery

BACKGROUND

The present study aimed to evaluate anatomical variations of the right hepatic artery (RHA) in patients with congenital biliary dilatation (CBD) and the appropriate approach in laparoscopic surgery for CBD.

METHODS

The medical records of 36 patients who underwent laparoscopic or open surgery for CBD from 1996 to 2018 were retrospectively reviewed. Radiological evaluation of the origin and course of the RHA in these 36 patients were compared with 195 control patients without CBD.

RESULTS

The incidence of the RHA crossing anterior to the common hepatic duct (CHD) was significantly higher in patients with CBD than in those without CBD (33% versus 10%, P = .0001). There was no intraoperative injury of the RHA, irrespective of the course of the RHA. The CHD was divided at the caudal side of the RHA in 11 of 12 patients (92%) with the anterior type of RHA, and in 13 of 24 patients (54%) with the posterior type of RHA (P = .03).

CONCLUSIONS

Patients with CBD had a higher incidence of the RHA crossing anterior to the CHD than patients without CBD. Preservation of the RHA in each situation is necessary during surgery for CBD in the era of laparoscopic surgery.

Hepatic artery classification based on three-dimensional CT

BACKGROUND

Precise classification of the hepatic artery is helpful for preoperative surgical planning in hepatobiliary-pancreatic surgery. However, the anatomy of hepatic arteries is variable. This study investigated anatomical variation using three-dimensional visualization and evaluation (3DVE) to develop a nomenclature system.

METHODS

The origin and course of the hepatic artery were tracked and analysed by using three-dimensional visualization of CT images acquired between 2013 and 2017. The new classification and nomenclature system, named CRL, was developed based on the origins of the common, right and left hepatic arteries.

RESULTS

Scans from 770 adults were evaluated. Preoperative 3DVE correlated better with surgical findings than the original CT images alone. Using the CRL classification system, hepatic arteries were divided into nine subtypes. Only 87·4-89·2 per cent of the hepatic arteries of 610 living-donor liver transplant donors were depicted in Michels', Hiatt's or Varotti's classification, compared with 100 per cent identified by the CRL classification. The CRL classification was validated against external data sets from previous studies, with 99·6-100·0 per cent of patients classified by the CRL system.

CONCLUSION

The CRL classification covers hepatic artery variants and may be used for planning liver surgery.

Virtual and Augmented Reality in Oncologic Liver Surgery

Virtual reality (VR) and augmented reality (AR) in complex surgery are evolving technologies enabling improved preoperative planning and intraoperative navigation. The basis of these technologies is a computer-based generation of a patient-specific 3-dimensional model from Digital Imaging and Communications in Medicine (DICOM) data. This article provides a state-of-the- art overview on the clinical use of this technology with a specific focus on hepatic surgery. Although VR and AR are still in an evolving stage with only some clinical application today, these technologies have the potential to become a key factor in improving preoperative and intraoperative decision making.

Application of three-dimensional visualization technique in preoperative planning of progressive hilar cholangiocarcinoma

OBJECTIVE

This study aims to investigate the role of three-dimensional visualization technique in the diagnosis and treatment of progressive hilar cholangiocarcinoma.

METHODS

From January 2014 to February 2017, a three-dimensional visualization model was set up in 23 patients with progressive hilar cholangiocarcinoma. The distributions and variations of the hepatic portal ducts were observed. The tumors were classified based on Bismuth classification. The simulation operation was performed and the operation plan was established.

RESULTS

All 23 patients revealed a clear relationship between the intrahepatic and extrahepatic ducts, as well as the tumors and ducts. An individualized surgery program was established through the accurate calculation of liver volume and residual liver volume. Among these patients, 13 patients completed radical resection of hilar cholangiocarcinoma combined with massive hepatectomy. No bile leakage occurred and no operative death was found.

CONCLUSION

For patients with progressive hilar cholangiocarcinoma, the optimized three-dimensional visualization technique can accurately demonstrate the dilated biliary tract system, provide a new standard to determine the presence of tumor and peripheral vascular invasion, help in establishing a reasonable individualized operation plan, reduce the incidence of bile leakage and liver failure after the operation, and improve the success rate of operation.

Management of centrally located hepatocellular carcinoma: Update 2016

Centrally located hepatocellular carcinoma (HCC) is sited in the central part of the liver and adjacent to main hepatic vascular structures. This special location is associated with an increase in the difficulty of surgery, aggregation of the recurrence disease, and greater challenge in disease management. This review summarizes the evolution of our understanding for centrally located HCC and discusses the development of treatment strategies, surgical approaches and recurrence prevention methods. To improve patient survival, a multi-disciplinary modality is greatly needed throughout the whole treatment period.

Recognition Accuracy Using 3D Endoscopic Images for Superficial Gastrointestinal Cancer: A Crossover Study

Aim. To determine whether 3D endoscopic images improved recognition accuracy for superficial gastrointestinal cancer compared with 2D images. Methods. We created an image catalog using 2D and 3D images of 20 specimens resected by endoscopic submucosal dissection. The twelve participants were allocated into two groups. Group 1 evaluated only 2D images at first, group 2 evaluated 3D images, and, after an interval of 2 weeks, group 1 next evaluated 3D and group 2 evaluated 2D images. The evaluation items were as follows: (1) diagnostic accuracy of the tumor extent and (2) confidence levels in assessing (a) tumor extent, (b) morphology, (c) microsurface structure, and (d) comprehensive recognition. Results. The use of 3D images resulted in an improvement in diagnostic accuracy in both group 1 (2D: 76.9%, 3D: 78.6%) and group 2 (2D: 79.9%, 3D: 83.6%), with no statistically significant difference. The confidence levels were higher for all items ((a) to (d)) when 3D images were used. With respect to experience, the degree of the improvement showed the following trend: novices > trainees > experts. Conclusions. By conversion into 3D images, there was a significant improvement in the diagnostic confidence level for superficial tumors, and the improvement was greater in individuals with lower endoscopic expertise.

Application of liver three-dimensional printing in hepatectomy for complex massive hepatocarcinoma with rare variations of portal vein: preliminary experience

BACKGROUND

To discuss the role of Liver 3D printing in the treatment of complex massive hepatocarcinoma with rare variations of portal vein.

METHODS

Data of enhanced computed tomography (CT) were imported into the medical image three-dimensional visualization system (MI-3DVS) to create Standard Template Library (STL) files, which were read by 3D printer to construct life-size 3D physical liver model. The preoperative surgical planning was performed on the 3D model according to individualized segmentation, volume calculation, and virtual operation.

RESULTS

The 3D printing liver model was consistent with the model in MI-3DVS. The segment 4 portal vein (S4PV) was absent and variant S4PV originated from right anterior portal vein (RAPV). The preoperative surgical planning was designed according to the relationship between tumor and portal vein variation. Theoretically, the residual liver volume was 40.76%, if the right hemihepatctomy was carried out after the trunk of right portal vein (RPV) ligated. However, the actual residual volume was only 21.37% due to the variant S4PV originates from RAPV, thus, right trisegmentectomy would have to be performed. Interestingly, after optimization, the residual liver volume increased to 57.25% as narrow-margin right hemihepatectomy with the variant S4PV reserved were performed. The final resection was determined to be narrow-margin right hemihepatectomy. The actual surgical procedure was consistent with the preoperative surgical planning.

CONCLUSION

Liver 3D printing may be a safe and effective technique to improve the success rate of surgery and reduce the operation risk for patients with complex massive hepatocarcinoma with variations of portal vein.