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目的探讨虚拟肝脏手术规划对中央型肝癌切除术的指导价值。方法应用虚拟肝脏手术规划系统软件Liv1.0对福建医科大学附属第一医院2007年6月至2012年6月49例病人进行虚拟中央型肝癌切除手术规划,将虚拟手术规划结果与手术中所见进行对比。结果 49例病人虚拟肝脏手术规划所测预切除肝脏体积为(543±225)mL,实际切除肝脏体积为(573±212)mL,平均误差(29±66)mL,两者间高度正相关(相关系数r=0.983,P<0.01)。结论针对中央型肝癌切除术,应用虚拟肝脏手术规划进行手术模拟,有利于评估肿瘤的可切除性并指导手术切除方式的选择。     

基于肝脏三维图像的肝段自动划分及虚拟解剖性肝切除

目的:利用肝脏三维图像进行肝内血管分析并自动划分肝段及虚拟解剖性肝切除术,以适应虚拟肝脏手术计划的要求.方法 基于患者螺旋CT断层扫描图像,应用自主研发的虚拟肝脏手术规划系统软件Liv1.0,对门静脉分支在段水平上进行标记,自动划分肝段范围并模拟解剖性肝切除术.结果 按照肝段血管的分布,软件自动分割出门静脉每个段分支分布的相应肝段范围,重建出以肝段划分为基础的肝脏三维模型,清楚、准确地显示各肝段分布范围和界限.在此基础上可行肝脏虚拟解剖性切除术及估算切除的肝脏体积.结论 利用软件Liv 1.0可清晰地重建肝脏及其管道系统三维图像,自动划分肝段并进行虚拟解剖性肝脏切除手术及肝脏体积测量.所有操作在个人计算机上完成,便于临床外科医生掌握,从而为虚拟肝脏技术在临床中的应用提供了一个软件平台.     

虚拟肝脏技术测量82例肝段体积的研究

目的 应用虚拟肝脏技术重建正常肝脏及肝段三维图像,测量各肝段体积,为肝脏外科手术提供指导.方法 16排螺旋CT扫描采集二维图像数据,应用自主开发的虚拟肝脏手术规划软件Liv1.0重建82例正常肝脏及各肝段三维图像,全方位显示肝脏及内部管道的图像信息,自动测量各肝段体积.结果 重建肝脏形态逼真,解剖标志清楚,肝内门静脉、肝静脉清晰显示,肝段内门静脉分支、肝静脉属支走行及相互关系明晰,肝段在肝脏表面分布如地图状,段间分界呈不规则波浪状.肝脏总体积为(1242 ±232)cm~3、Ⅰ段体积(20±7)cm~3、Ⅱ段(153±49)cm~3、Ⅲ段(129±36)cm~3、Ⅳ段(160±46)cm~3、Ⅴ段(209±50)cm~3、Ⅵ段(142±49)cm~3、Ⅶ段(173±58)cm~3、Ⅷ段(256±73)cm~3,分别占全肝体积的百分比为(1.6±0.6)%、(12.3±3.5)%、(10.4±3.0)%、(14.2±3.7)%、(16.3 ±4.2)%、(12.0 ±3.6)%、(13.9±4.4)%、(20.5±6.3)%.左半肝(Ⅱ、Ⅲ、Ⅳ、段)体积为(445±96)cm~3,占全肝体积的百分比(35.8±6.8)%,右半肝(Ⅴ、Ⅵ、Ⅶ、Ⅷ段)体积为(796±135)cm~3,占全肝体积的百分比(64.1±12.0)%.结论 虚拟肝脏手术规划软件Liv1.0重建肝脏及肝段图像清晰逼真,测得肝段体积具体数据,对活体肝移植、肝段为本的肝切除术具有一定的指导意义.     

三维可视化系统在肝门部胆管癌治疗中的应用

目的 探讨三维可视化系统在肝门部胆管癌治疗中的应用价值.方法 回顾性分析2012年1月至9月厦门大学附属成功医院收治的10例肝门部胆管癌患者的临床资料,采用三维可视化系统将CT二维图像转换成三维图像,测量肝脏体积、肿瘤体积、预切除肝脏体积、剩余肝脏体积,并在三维图像上制订预手术方案,模拟肿瘤切除,按照根治理念进行手术,术后比较实际手术方案与预手术方案的区别.术前预切除肝脏体积与术后实际切除肝脏体积的相关性检验采用Pearson等级相关分析.结果 本组10例患者均成功进行三维重建,测得平均肝脏体积为(1496±162) ml,肿瘤平均体积为(67±18) ml,预切除肝脏平均体积为(335±241)ml,剩余肝脏平均体积为(1140±197)ml.预切除肝脏体积的平均误差率为6.4％.本组患者按照根治性切除原则进行手术方案制订,左半肝切除4例、右半肝切除2例、局部切除3例、姑息性切除1例.模拟手术方案与实际手术方式符合率为9/10.实际行R0切除7例、R1切除1例、姑息性切除2例,其中l例行限制性门静脉动脉化.根据术中探查证实,术前三维可视化重建对重要血管、胆管及肿瘤的解剖学评估结果与术中所见大致相符.术前三维可视化对肿瘤分型诊断准确率为8/10.实际切除肝脏平均体积为(325±258) ml,术前预切除肝脏体积与术后实际切除肝脏体积呈正相关(r=0.902,P＜0.05).结论 三维可视化系统在肝门部胆管癌治疗中具有一定的临床应用价值.     

虚拟肝切除技术在肝癌切除中的临床应用

目的 探讨虚拟肝切除技术在肝癌切除中的价值.方法 2007年9月至2008年9月对13例肝癌病人术前行常规Flash3D增强扫描,用3D-Doctor软件行包括下腔静脉、门静脉、肝静脉和肝短静脉的三维影像重建,测量全肝体积、肿瘤体积、拟切除的肝脏体积、余肝体积和余肝体积/标准肝体积(SFLVR).结果 7例行右半肝切除,6例肝段/叶切除.肝脏三维重建后均能从各个角度显示肝内静脉走向及与肿瘤的空间关系,肿瘤体积为(348±214)ml,拟切除肝体积为(676±375)ml,余肝体积为(714±261)ml,SFLVR为62%±19%.术后并发症包括肺1例肺部感染,中等量腹水6例,大量腹水2例,其中1例肝功能不全.结论 虚拟肝切除技术能直观显示肝脏静脉以及与肿瘤的关系,预测肝切除量,对制定肝脏手术方案具有实用价值.     

三维可视化技术辅助解剖性肝切除术的应用体会

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。     

Study on the application of three-dimensional visualization technique in evaluation of residual liver volume and guidance for hepatectomy

目的 研究三维可视化技术在肝脏肿瘤术前评估及指导精准肝切除中的临床应用.方法 采集10例入住我院的肝脏肿瘤患者术前64排螺旋CT亚毫米原始扫描数据,再运用腹部医学图像三维可视化系统(MI-3DVS)进行图像分割及三维重建,观察重建模型进而仿真手术,计算残肝体积百分比,结合患者临床资料评估手术风险,将仿真手术与真实手术全过程,术前风险评估及真实预后情况进行对比分析.结果 MI-3 DVS对腹部脏器及其脉管系统三维重建的模型结构清晰、直观、形象逼真.10例患者功能肝体积介于(1335.28±293.72)ml;肿瘤体积介于(399.06±276.26)ml;残肝体积介于(770.12±226.77)ml;结合患者临床资料,10例患者术前测得的残肝体积百分比均能满足术后肝功代偿要求,仿真手术与真实手术全过程一致,术前利用MI-3DVS手术风险评估与真实手术风险一致.结论 三维可视化技术对指导肝脏肿瘤手术方案的制定,提高肝脏肿瘤切除率,评估手术风险,降低手术并发症的发生率意义重大.     

数字化三维重建系统在肝泡型包虫病治疗中的应用

目的 探讨数字化三维重建系统在肝泡型包虫病(HAE)治疗中的应用价值.方法 采用数字化三维重建系统对2011年2月至10月新疆医科大学第一附属医院收治的13例HAE患者的肝脏CT检查数据进行三维重建及智能分析,术前评估可切除性,设计合理的手术方案,完成术前个体化虚拟手术,并与术中实际情况作比较.结果 13例患者CT检查数据三维重建结果满意,肝内病灶及相关管道关系显示清晰.l例患者行体外肝切除+自体肝移植术,10例行肝切除术,2例行PTCD,与虚拟手术设计方案一致.术前通过三维重建系统对11例拟行手术的患者进行虚拟手术设计,测得预切除肝脏平均体积为920 ml(339～2678ml);切除肝脏体积占全肝体积平均为45％(23％～68％).患者实际切除肝脏平均体积为834 ml(315 ～2250 ml);术中切除肝脏体积占全肝体积平均为42％ (22％ ～70％),与术前三维重建结果基本一致.术后随访2～8个月,所有患者未出现肝功能衰竭、出血、胆汁漏等严重并发症.结论 数字化三维重建系统有助于确定HAE合理的手术方式,有效降低了手术风险.     

三维可视化技术在评估残肝体积及指导肝切除中的应用研究

目的研究三维可视化技术在肝脏肿瘤术前评估及指导精准肝切除中的临床应用。方法采集10例入住我院的肝脏肿瘤患者术前64排螺旋CT亚毫米原始扫描数据,再运用腹部医学图像三维可视化系统(MI-3DVS)进行图像分割及三维重建,观察重建模型进而仿真手术,计算残肝体积百分比,结合患者临床资料评估手术风险,将仿真手术与真实手术全过程,术前风险评估及真实预后情况进行对比分析。结果 MI-3DVS对腹部脏器及其脉管系统三维重建的模型结构清晰、直观、形象逼真。10例患者功能肝体积介于(1335.28±293.72)ml;肿瘤体积介于(399.06±276.26)ml;残肝体积介于(770.12±226.77)ml;结合患者临床资料,10例患者术前测得的残肝体积百分比均能满足术后肝功代偿要求,仿真手术与真实手术全过程一致,术前利用MI-3DVS手术风险评估与真实手术风险一致。结论三维可视化技术对指导肝脏肿瘤手术方案的制定,提高肝脏肿瘤切除率,评估手术风险,降低手术并发症的发生率意义重大。     

虚拟肝脏手术规划系统预测肝癌肝切除术后肝功能损害的价值

目的 应用虚拟肝脏手术规划系统测量肝癌肝切除术后剩余肝脏体积,评估剩余肝脏体积比(STELR)在预测术后肝功能损害的价值.方法 回顾性分析2007年4月至2011年10月福建医科大学附属第一医院收治的76例原发性肝癌患者的临床资料,术前利用虚拟肝脏手术规划系统进行虚拟肝切除,测量剩余肝脏体积.应用ROC曲线计算STELR的临界值,利用单因素分析和Logistic回归模型分析各危险因素对术后肝功能损害的影响.结果 本方法所测预切除肝脏体积为(489±206)ml,实际切除肝脏体积为(459±199)ml,两者呈正相关(r=0.916,P＜0.05).经量化指标计算,76例患者中,肝功能损害轻度48例,中度19例,重度9例.ROC曲线截断点对应的STELR为53％,STELR≥53％的患者有3％(2/59)发生重度肝功能损害;STELR＜ 53％的患者有41％ (7/17)发生重度肝功能损害,两者比较,差异有统计学意义(x2=5.085,P＜0.05).单因素分析显示手术时间、术中出血量和STELR与肝切除术后肝功能损害程度相关(F -7.227,8.630,13.809,P＜0.05).Logistic回归模型分析表明STELR是重度肝功能损害的独立预测因素(Wald=6.675,P＜0.05).结论 STELR可以有效预测肝癌肝切除术后肝功能损害的风险.     

Three-dimensional visualization and virtual simulation of resections in pediatric solid tumors

Purpose

Three-dimensional visualization of solid tumors is possible because of high-resolution computed tomography and magnetic resonance imaging scans. However, additional preoperative information is often desirable in complex malignancies. For the first time, the authors present a model of preoperative 3-dimensional visualization and virtual resections in pediatric solid tumors.

Methods

Image analysis of various pediatric tumors was performed using the research software HepaVision2 (MeVis, Bremen). Organs, tumors, and the vascular system were extracted from multislice computed tomography scans. After hierarchical analysis of the vascular system, territories supplied or drained by the major vascular branches were calculated. Results were explored and virtual resections of organs were carried out using the research software InterventionPlanner (MeVis, Bremen). Data were correlated to intraoperative findings.

Results

Four hepatic malignancies, 4 renal tumors, and 3 other neoplasms were analyzed. The technique of 3-dimensional visualization was feasible for all investigated children (mean age 5 years and 9 months). Spatial relations between physiological and pathological structures were identified, and anatomical structures (vessels, tumor tissue, and organ parenchyma) were determined using colorimetric encoding. Virtual simulations of tumor resection were used successfully for planning of surgical procedures in the hepatic and renal tumors.

Conclusions

The technique of 3-dimensional tumor visualization and virtual simulation of tumor resections provides the basis for a successful planning of complex tumor resections in children. The efficiency of these techniques should be further analyzed in series with higher numbers and differentiations of tumors.     

三维可视化技术在复杂性肝癌切除术中应用研究

目的 探讨三维可视化技术在复杂性肝癌切除术中的临床应用价值。方法 回顾性分析2019年3月至2020年3月福建医科大学附属肿瘤医院肝胆胰外科收治的23例复杂型肝癌病人资料,运用三维可视化技术重建肝脏三维模型行虚拟肝切除,进行手术的病人比较虚拟肝切除体积与实际肝切除体积的差别,并观察病人术后并发症发生的情况。结果 23 例病人中20例完成了手术治疗。术中均未损伤重要血管,术后均未出现出血、肝功能衰竭等严重并发症,手术病人均康复出院。病人虚拟肝切除体积与实际切除体积比较,差异无统计学意义（t=0.447,P＞0.05）,相关性分析显示成正相关（r=0.982,P＜0.01）。结论 三维可视化技术具有清晰显示肝内脉管系统及其与肿瘤的毗邻关系、计算残肝体积、最优化模拟手术路径、协助医患术前沟通等优点,临床应用于复杂性肝癌,有助于预判手术风险,制定个体化的手术方案,降低术后并发症发生率。     

肝内血管三维重建及风险分析对肝切除手术规划的意义

目的探讨肝内血管三维重建及风险分析对肝切除手术规划的意义。方法采集28例拟行肝切除患者的肝脏CT二维(2D)扫描数据,利用3D图像处理软件LiverAnalyzer进行肝内血管三维重建、风险分析及模拟肝切除,并以此指导肝切除手术规划。结果成功进行了肝脏、肿瘤和肝内血管的三维重建、风险分析、模拟肝切除及手术规划,并据此进行了临床治疗。28例中6例行行非手术疗法,其余22例均行肝切除(半肝切除3例,局部切除19例),手术均顺利,术后肝功能恢复良好,无明显并发症。随访至今(2~29个月)除1例远隔部位复发带瘤生存外,其余患者均无瘤生存。结论肝内血管三维重建及风险分析有助于肝切除手术规划,包括进一步判断肿瘤可切除性、选择手术入路以及使肝癌的局部切除成为解剖性切除等。     

计算机辅助手术规划系统在精准肝切除中的应用价值

目的 评价计算机辅助手术规划系统在精准肝切除中的临床应用价值.方法 回顾性分析2006年11月至2009年11月解放军总医院对45例肝癌患者通过计算机辅助手术规划系统进行精准肝切除治疗的临床资料.术前通过计算机辅助手术规划系统进行肝脏三维重建,对肝脏血管结构及其与肿瘤的解剖关系进行二维和三维分析;分别计算肝段体积、肿瘤体积、全肝体积、预切除肝脏体积和剩余肝脏体积,切除标本术后称重并与预切除肝脏体积比较;实施虚拟肝切除,优化手术方案.采用t检验、Pearson相关分析、X~2检验分析检测结果.结果 术前预切除肝脏体积采用二维方法计算的结果与采用三维方法计算的结果比较,差异无统计学意义(t=2.125,P>0.05).计算机辅助手术规划系统能够清晰显示肝动脉、门静脉和肝静脉等血管结构的三级分支,对肿瘤与毗邻血管的空间解剖关系进行量化分析,精确测算血管所支配的功能体积,当预测的切除肝脏体积越大,切除标本质量越大(r=0.999,P<0.05),误差率为5.1%.全组患者均进行了解剖性肝切除,手术并发症发生率为20%(9/45),均通过保守治疗好转.术后无肝功能衰竭发生,无围手术期死亡.结论 计算机辅助手术规划系统能够优化手术方案,是开展精准肝切除的有益辅助工具.     

Virtual hepatic resection using three-dimensional reconstruction of helical computed tomography angioportograms

OBJECTIVE: To establish the accuracy of virtual hepatic resection using three-dimensional (3D) models constructed from computed tomography angioportography (CTAP) images in determining the liver volume (LV) resected during resectional liver surgery. SUMMARY BACKGROUND DATA: The ability to measure LV before surgery could be useful in determining the extent and nature of hepatic resection. Accurate assessment of LV and an estimate of liver function may also allow prediction of postoperative liver failure in patients undergoing resection, assist in volume-enhancing embolization procedures, help with the planning of staged hepatic resection for bilobar disease, and aid in selection of living-related liver donors. METHODS: A retrospective study was conducted involving 27 patients scheduled for liver resection. Using mapping technology, 3D models were constructed from helical CTAP images. From these 3D models, tumor volume, total LV, and functional LV were calculated and were compared with body weight. The 3D liver models were subjected to a virtual hepatectomy along established anatomical planes, and the resected LV was calculated. The resected volume predicted by radiologists (unaware of the actual weight) was compared with the specimen weight measured after actual surgical resection. RESULTS: A significant correlation was found between body weight and functional LV but not total LV. The computer prediction of resected LV after virtual hepatectomy of 3D models compared well with resected liver weight. CONCLUSION: Virtual hepatectomy of 3D CTAP reconstructed images provides an accurate prediction of liver mass removed during subsequent hepatic resection. The authors intend to combine this technology with an assessment of liver function to attempt to predict patients at risk for liver failure after hepatic resection.     

Liver resection in benign and malignant tumors]

Benign tumors of the liver, circumscribed hepatomas and solitary hepatic metastases from colonic cancer are treated by partial liver resection. In case of colonic cancer the hepatic metastasis is resected in a second operation. 20 cases of hepatic resections are reported. 10 right hepatic lobectomies, 1 left hepatic lobectomy and 9 minor resections were performed. Of the 11 patients treated by hepatic lobectomy, one (or 9%) died in the postoperative period (within 30 days after operation). Of the other 9 patients undergoing minor resections there was no death.     

Role for extending hepatic resection using an aggressive approach to liver surgery

BACKGROUND: The definition of what is unresectable in liver surgery is controversial. Problems that many believe render patients unresectable can currently be resected using advanced techniques of liver surgery. This study assesses liver resection in patients who were unresectable with standard liver resection but were potentially resectable using an aggressive approach to liver surgery. STUDY DESIGN: From 1997 to 2007, 830 adult patients undergoing hepatectomy were reviewed. Patients were categorized as having unresectable disease by standard resection if the disease could not be resected without resection of the IVC, hepatic vasculature, or because of tumor extent. RESULTS: One hundred sixteen patients were initially believed to have unresectable disease but went on to laparotomy. Eighteen patients were unresectable at operation, although 98 patients were resected. Seventy-eight trisectionectomies; 18 lobectomies; 1 mesohepatectomy; and 1 segment 5, 6 resection, combined with pancreaticoduodenectomy, nephrectomy, and colectomy, were performed. Fourteen patients also had pancreatic resections. Vascular reconstructions were performed on the IVC (n = 35), hepatic veins (n = 21), portal vein (n = 34), and hepatic artery (n = 5). Hypothermic perfusion of the liver was used in 12 patients (4 ex vivo, 8 in situ cold perfusion). Patients undergoing resection had 6% mortality with a morbidity of 35%. Median survival was 37 months (95% CI, 34-42 months). Five-year actuarial survival was 32%. CONCLUSIONS: Patients with liver tumors considered "unresectable" by standard liver resection should be considered for resection with an aggressive approach to liver surgery. Five-year survival of approximately one-third of patients can be expected.     

肝内血管的三维重建及肝癌局部解剖性切除

目的 探讨肝内血管三维(3D)成像在肝癌局部切除中的意义.方法 将64排螺旋CT扫描获得的肝癌患者的肝脏二维图像数据,以DICOM文件格式导入3D模拟系统进行肝内血管3D重建;在重建的肝内血管3D图像指导下行肝癌局部肝切除.结果 (1)经过重建得到了清晰的肝内血管以及肝脏和肝癌的3D图像,该图像立体地显示了肝癌与周围诸血管的解剖关系.(2)在3D图像上模拟不同肿瘤切缘宽度得到肝癌周围肝动脉、门静脉和肝静脉的切断平面和各血管切断后所影响的肝组织体积.(3)分析肿瘤的切缘宽度与切肝体积间的关系,拟定出肝癌局部切除的最佳切肝平面.(4)按拟定的切肝平面行实际肝切除,切除标本体积为178 ml,肿瘤切缘为9 mm,结果与术前模拟完全吻合.结论 在肝内血管3D图像指导下,肝癌的局部切除可以按肿瘤周围血管的解剖精确进行;通过术前模拟可以找到最佳肝切除平面.