三维可视化技术辅助解剖性肝切除术的应用体会
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摘要
目的探讨三维可视化技术辅助解剖性肝切除术的应用价值。方法回顾性分析2016年1月至2017年12月临沧市人民医院肝胆外科行三维可视化技术辅助解剖性肝切除术78例肝肿瘤及肝胆管结石患者的临床资料。将患者上腹部增强CT扫描数据导入Slicer三维软件,构建肝脏三维可视化图像模型,明确肝内血管走行及解剖分型,肿瘤所处的肝叶与肝段,肿瘤的大小、数目,肿瘤与血管的三维空间比邻。计算全肝体积、肿瘤体积、拟切除标本体积、残肝体积、功能性肝体积、残肝体积比。术前判断切除的肝叶/肝段及切除的血管,根据残肝体积评估患者肝脏储备功能,准确进行手术风险评估。术中根据肿瘤实际侵犯情况,纠正影像学的偏差,再决定切除范围。结果 78例患者术前均完成三维可视化图像重建,均采用三维可视化技术完成解剖性肝切除术。术前虚拟切除肝体积(1 020±264)mL,实际切除肝体积(1 125±267)mL,二者无统计学差异(P> 0.05)。手术时间(210±54)min,术中出血量(671±231)mL,术后住院时间(18.5±3.2)d,术后并发症率15.4%,围手术期死亡1例。解剖性肝切除术中,按照术前模拟方案完成手术69例(88.5%),9例因肿瘤侵犯血管或实际残肝体积与手术规划方案有偏差更改切除范围。结论三维可视化技术有助于精确判断肿瘤侵犯血管、胆管情况,确定安全的肝切除量和范围,优化手术方案,提高解剖性肝切除术的疗效。
Objective To explore the application value of three-dimensional visualization technology in anatomic hepatectomy. Methods Retrospective analysis was conducted in 78 patients with hepatic tumor and hepatolithiasis who underwent three-dimensional visualization(3D) assisted anatomic hepatectomy in Lincang People's Hospital from Jan. 2016 to Dec. 2017. Patients' upper abdominal enhanced CT scan data was imported into Slicer 3D software and 3D visualization model of liver was constructed succesfully, which could clearly show intrahepatic blood vessels and anatomy of the liver, location in liver lobe and liver segment of tumor, size and number of tumors, 3D adjacent space intrahepatic blood vessel and tumor. Total liver volume, tumor volume, resection specimen volume, residual liver volume, functional liver volume and residual liver volume ratio were calculated. Hepatic lobe/liver segment and the removed vessels were determined preoperative. Surgical risk was assessed including hepatic lobe/liver segment and the removed vessels and reserved liver function according to the residual volume liver. The imaging deviation according to the actual invasion of the tumor was corrected and then the extent of resection intraoperative was estimated. Results The liver 3D models for all patients were constructed successfully, and 3D visualization technique was used to complete anatomical liver resection for all patients. Preoperative virtual hepatectomy volume was(1 020±264) mL, and the actual volume was(1 125±267) mL. There was no satistical defference between them(P>0.05). The operation time was(210±54) min, intraoperative bleeding was(671±231)mL, postoperative hospitalization was(18.5±3.2) d, postoperative complication rate was 15.4%, perioperative death occurred in 1 case. In anatomic hepatectomy, according to the preoperative simulation, 69 cases(88.5%) were completed. In 9 cases, the volume of tumor invasion or the actual residual liver volume was deviated from the surgical planning and the extent of resection was changed. There was no significant difference between the virtual hepatectomy volume and the actual liver volume(P>0.05). Conclusion Three-dimensional visualization technique helps to accurately determine the situation of tumor invasion of blood vessels and bile ducts, and determines the amount and scope of safe hepatectomy, optimizes the operation plan, and improves the curative effect of anatomical hepatectomy.
Objective To explore the application value of three-dimensional visualization technology in anatomic hepatectomy. Methods Retrospective analysis was conducted in 78 patients with hepatic tumor and hepatolithiasis who underwent three-dimensional visualization(3D) assisted anatomic hepatectomy in Lincang People's Hospital from Jan. 2016 to Dec. 2017. Patients' upper abdominal enhanced CT scan data was imported into Slicer 3D software and 3D visualization model of liver was constructed succesfully, which could clearly show intrahepatic blood vessels and anatomy of the liver, location in liver lobe and liver segment of tumor, size and number of tumors, 3D adjacent space intrahepatic blood vessel and tumor. Total liver volume, tumor volume, resection specimen volume, residual liver volume, functional liver volume and residual liver volume ratio were calculated. Hepatic lobe/liver segment and the removed vessels were determined preoperative. Surgical risk was assessed including hepatic lobe/liver segment and the removed vessels and reserved liver function according to the residual volume liver. The imaging deviation according to the actual invasion of the tumor was corrected and then the extent of resection intraoperative was estimated. Results The liver 3D models for all patients were constructed successfully, and 3D visualization technique was used to complete anatomical liver resection for all patients. Preoperative virtual hepatectomy volume was(1 020±264) mL, and the actual volume was(1 125±267) mL. There was no satistical defference between them(P>0.05). The operation time was(210±54) min, intraoperative bleeding was(671±231)mL, postoperative hospitalization was(18.5±3.2) d, postoperative complication rate was 15.4%, perioperative death occurred in 1 case. In anatomic hepatectomy, according to the preoperative simulation, 69 cases(88.5%) were completed. In 9 cases, the volume of tumor invasion or the actual residual liver volume was deviated from the surgical planning and the extent of resection was changed. There was no significant difference between the virtual hepatectomy volume and the actual liver volume(P>0.05). Conclusion Three-dimensional visualization technique helps to accurately determine the situation of tumor invasion of blood vessels and bile ducts, and determines the amount and scope of safe hepatectomy, optimizes the operation plan, and improves the curative effect of anatomical hepatectomy.
引文
[1]尹新民,朱斯维.腹腔镜解剖性半肝切除术技巧及关键技术[J].中国实用外科杂志,2017,37(5):477-481.
[2]李留峥,徐雷升,俸家伟,等.Glisson蒂横断式解剖性肝切除120例体会[J].肝胆胰外科杂志,2017,29(5):359-362.
[3]Takasaki K著,吕毅,李宗芳主译.Glisson蒂横断式肝切除术[M].北京:人民卫生出版社,2008:23-76.
[4]黄锦龙,王清,于勇,等.解剖性肝切除对肝细胞癌预后的影响[J].第二军医大学学报,2015,36(5):492-496.
[5]王峻峰,孙志为,王罡,等.3D打印模型在肝脏肿瘤切除手术中的应用[J].中国现代医学杂志,2017,27(3):136-138.
[6]杨俭,谭一非,蒋利,等.应用3D打印技术辅助精准肝切除术[J].中国普外基础与临床杂志,2018,25(1):71-76.
[7]杨剑,方驰华,范应方,等.基于亚毫米CT扫描数据的肝外胆管供血动脉三维可视化模型构建[J].南方医科大学学报,2014,34(7):945-949.
[8]中华医学会数字医学分会,中国研究型医院学会数字医学临床外科专业委员会.肝门部胆管癌三维可视化精准诊治专家共识[J].中国实用外科杂志,2017,37(1):48-52.
[9]方兆山,刘星星.3D打印在肝脏外科应用的研究进展[J].中国医学物理学杂志,2015,32(3):374-378.
[10]侯建存,张雅敏,王连江,等.肝脏影像解读分析系统在精准肝切除手术规划中的应用[J].中国普外基础与临床杂志,2014,21(2):142-145.
[11]熊永福,闫再华,杨召,等.肝脏影像分析解读系统在肝脏手术规划中的应用[J].临床肝胆病杂志,2015,31(8):1317-1320.
[12]方驰华,方兆山,蔡伟,等.肝胆管结石三维可视化诊治平台构建及临床价值研究[J].中国实用外科杂志,2015,35(8):974-978.
[13]李留峥,徐雷升,俸家伟,等.解剖性肝切除术治疗复杂肝内胆管结石体会[J].腹部外科杂志,2017,30(6):456-459.
[14]徐安书,傅朝春,韦萍,等.D打印技术在精准切除治疗肝脏肿瘤中的应用[J].中国普通外科杂志,2018,27(1):29-34.
[15]Radtke A,Sotiropoulos GC,Molmenti EP,et a1.Computerassisted surgery planning for complex liver rescetions:when is it helpful?A single-center experience over an 8-year period[J].Ann Surg,2010,252(5):876-883.
[2]李留峥,徐雷升,俸家伟,等.Glisson蒂横断式解剖性肝切除120例体会[J].肝胆胰外科杂志,2017,29(5):359-362.
[3]Takasaki K著,吕毅,李宗芳主译.Glisson蒂横断式肝切除术[M].北京:人民卫生出版社,2008:23-76.
[4]黄锦龙,王清,于勇,等.解剖性肝切除对肝细胞癌预后的影响[J].第二军医大学学报,2015,36(5):492-496.
[5]王峻峰,孙志为,王罡,等.3D打印模型在肝脏肿瘤切除手术中的应用[J].中国现代医学杂志,2017,27(3):136-138.
[6]杨俭,谭一非,蒋利,等.应用3D打印技术辅助精准肝切除术[J].中国普外基础与临床杂志,2018,25(1):71-76.
[7]杨剑,方驰华,范应方,等.基于亚毫米CT扫描数据的肝外胆管供血动脉三维可视化模型构建[J].南方医科大学学报,2014,34(7):945-949.
[8]中华医学会数字医学分会,中国研究型医院学会数字医学临床外科专业委员会.肝门部胆管癌三维可视化精准诊治专家共识[J].中国实用外科杂志,2017,37(1):48-52.
[9]方兆山,刘星星.3D打印在肝脏外科应用的研究进展[J].中国医学物理学杂志,2015,32(3):374-378.
[10]侯建存,张雅敏,王连江,等.肝脏影像解读分析系统在精准肝切除手术规划中的应用[J].中国普外基础与临床杂志,2014,21(2):142-145.
[11]熊永福,闫再华,杨召,等.肝脏影像分析解读系统在肝脏手术规划中的应用[J].临床肝胆病杂志,2015,31(8):1317-1320.
[12]方驰华,方兆山,蔡伟,等.肝胆管结石三维可视化诊治平台构建及临床价值研究[J].中国实用外科杂志,2015,35(8):974-978.
[13]李留峥,徐雷升,俸家伟,等.解剖性肝切除术治疗复杂肝内胆管结石体会[J].腹部外科杂志,2017,30(6):456-459.
[14]徐安书,傅朝春,韦萍,等.D打印技术在精准切除治疗肝脏肿瘤中的应用[J].中国普通外科杂志,2018,27(1):29-34.
[15]Radtke A,Sotiropoulos GC,Molmenti EP,et a1.Computerassisted surgery planning for complex liver rescetions:when is it helpful?A single-center experience over an 8-year period[J].Ann Surg,2010,252(5):876-883.