虚拟肝脏手术规划应用于肝切除术的研究

目的 探讨虚拟肝脏手术规划对肝切除术的指导价值.方法 基于患者螺旋cT断层图像,应用自主研发的虚拟肝脏手术规划系统软件Liv 1.0对2007年5月至2009年5月收治的142例肝肿瘤患者进行虚拟肝脏手术规划,将虚拟手术规划结果与手术中所见进行对比.结果 (1)重建的142例三维可视化肝脏效果满意,清晰显示肝肿瘤的大小、位置、数目及其与肝内管道的空间毗邻关系,并可从任意角度观察,与术中所见匹配良好.(2)通过虚拟肝脏手术规划,可显示肝切除过程中需切除或保留的肝内管道,计算出余肝组织可能出现缺血和淤血的范围;通过反复的手术模拟,改变手术切除界限,优化手术方案.其中29例经CT图像判断无法切除而应用该系统进行手术规划后完整切除肿瘤,92例经虚拟手术后优化了手术方案.(3)127例肝癌患者虚拟肝脏手术规划所测预切除肝脏体积为(477±223)ml,实际切除肝脏体积为(451±209)ml,误差率为6.1%,两者间呈正相关(R=0.922,P<0.01).结论 应用软件Liv 1.0进行肝脏三维重建及虚拟肝脏手术规划可以为复杂的肝切除术提供重要的术前参考,有利于提高手术预见性和安全性,有利于提高复杂性肝切除的成功率.     

Intraoperative ultrasonography in surgery for liver tumors

Intraoperative ultrasonography was used in 37 patients during surgery for suspected liver tumors. The size, number, and site of the lesions were determined together with the relationship of the tumor to the intrahepatic vessel, as well as possible small daughter lesions within the liver. Final diagnosis in these patients was hepatocellular carcinoma in 19 cases, metastases from colorectal cancers in 15 cases, and benign lesions in three cases. Previously undetected small tumors were revealed in one patient with sigmoid cancer and in five patients with liver cell carcinoma who had cirrhosis. Vascular tumoral infiltrations were easily displayed and the surgical approach modified accordingly: a more extended resection was performed in two cases of huge central hepatic metastases. Intraoperative ultrasonography revealed seven cases of small (2 to 3 cm) hepatocellular carcinomas in cirrhotic livers that were not visible or palpable, thus allowing a subsegmentary resection. Finally, in three cases of atypical tumors, an intraoperative echo-guided biopsy specimen was required to establish the benign nature of lesions and resection was avoided. Intraoperative ultrasonography facilitates the diagnosis of small liver tumors and can also aid the surgeon in his choice of technique, especially in cases of cirrhosis of the liver. A resection can be avoided altogether when multiple lesions are involved, or echo-guided subsegmentary resections can be performed in cirrhotic livers when a less extended resection is required. This technique makes it possible to establish the relationship between the tumor and intrahepatic vessels, thus preventing vascular injury and making radical hepatic resection safer.     

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目的　探讨多排螺旋CT三维重建在肝脏外科中的应用价值。方法　 2 0 0 2年 4月至 2 0 0 3年 10月对2 0例肝脏肿瘤病人术前行 16层螺旋CT增强扫描 ,并在CT工作站上应用多排螺旋CT表面容积重建及多平面容积重建软件行肝动脉、门静脉和肝静脉的三维影像重建 ,测量全肝体积、肝肿瘤体积及拟切部分肝脏体积 (包括肿瘤体积 ) ,观察病人术后血清谷丙转氨酶、总胆红素、血氨水平及腹水情况 ,计算病人残肝体积与标准肝体积之比。结果　 2 0例病人经肝血管三维重建后均能从各个角度显示肝动脉、门静脉和肝静脉结构 (肝动脉可显示 2～3级分支 ,门静脉 3～ 4级分支 )、肝动脉变异情况、肿瘤与周围血管的关系。经三维重建后测得预切除肝脏体积平均为 4 78 75cm3 ,肿瘤体积平均为 374 6 5cm3 ,与手术切除标本所测体积基本符合 (P >0 0 5 )。残肝体积与标准肝体积之比小于 5 0 %时 ,病人术后肝功能重度损害的可能性增加。结论　多排螺旋CT三维重建技术能帮助术者在术前更直观地了解肝血管解剖关系、肿瘤与周围血管关系 ,对制定更完善的手术方案具有实用价值。多排螺旋CT三维重建可较准确测量肝体积 ,残肝体积与标准肝体积比值可帮助预测术后肝功能恢复情况。     

基于64排螺旋CT扫描数据三维肝脏手术仿真的研究

目的研究基于64排螺旋CT扫描数据的三维肝脏虚拟手术的设计和仿真效果,以及基于自由设计模型系统（FreeForm Modeling System）的虚拟手术的可行性。方法采集正常人肝脏64排薄层扫描数据集,利用医学三维重建软件（MIMICS软件）进行肝脏及其肝内血管三维重建,并将重建的肝脏及其管道模型、人工绘制肝脏肿瘤模拟物导入FreeForm Modeling System,利用力反馈设备（PHANTOM）,对肝脏模型进行手术切割。结果通过旋转和放大目标物体,肿瘤与肝内血管的立体关系能清晰展示。根据手术原则,使用PHANTOM操纵“手术刀”,仿真左外叶切除,术中肝内管道结构容易识别,其过程基本符合临床肝脏肿瘤切除的手术过程并可调节目标物体的强度,感受切割时力反馈的大小。结论利用FreeForm Modeling System虚拟手术系统仿真肝脏手术切割,可以制定合理的个体化手术方案,减少并发症发生,提高手术成功率。     

Peroperative exploration of the liver in hepatic tumor surgery

Intraoperative exploration of the liver and complete abdominal examination are essential before hepatic resection for patients with liver tumors. The surgeon's eye and hand, traditional methods of exploration, are still accurate for abdominal exploration, screening of small superficial liver tumors and evaluation of non-tumoral liver parenchyma. Intraoperative ultrasonography is often superior to preoperative screening methods in diagnosing small liver tumors. Intraoperative ultrasonography identifies variations of intrahepatic vascular structures and reveals exact location of tumors according to functional anatomy. The surgeon's eye and hand and intraoperative ultrasound are complementary for a complete exploration, and may affect operative decision making. Laparoscopy and laparoscopic ultrasonography, when diagnosing non resectable tumors, reduce the number of unnecessary laparotomies. However, the effectiveness of exploration by laparoscopy and laparoscopic ultrasonography is lower than that of laparotomy, which remains indispensable before hepatic resection for malignant tumors.     

计算机辅助手术系统在儿童肝脏原发性间叶肿瘤手术中的应用

目的 探讨Hisense CAS计算机辅助手术系统在儿童肝脏原发性间叶肿瘤手术中的应用优势。方法 收集2009年4月至2020年11月在青岛大学附属医院接受肝脏间叶肿瘤手术的8例肝脏间叶源性肿瘤患儿的临床资料,其中男3例,女5例,年龄0.9～9岁;间叶错构瘤4例,胚胎性肉瘤4例。其中4例运用Hisense CAS计算机辅助手术系统对其增强CT数据进行三维重建。结果 术前根据CT检查拟实施精准肝切除术,4例成功进行肝脏及肿瘤的三维重建,并进行模拟肝切除。根据术前制定的手术计划成功实施肝中叶切除术2例,肝右叶切除术1例,肝左叶切除术2例,肝脏肿瘤切除术3例。术后恢复好,病理检查证实皆为肝脏间叶肿瘤。随访3个月至5年未见并发症及复发。结论 肝脏间叶肿瘤影像学特征不明显,很难与其他肝脏肿瘤区分,肿瘤体积较大,术前规划难度较高,Hisense CAS计算机辅助手术系统的3D可视化技术能补充CT检查结果,辅助医师设计最优手术方案,有助于安全根治性切除肿瘤。     

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.     

虚拟中国人女性一号肝脏图像三维重建和虚拟手术的切割

目的研究数字化虚拟肝脏三维重建及虚拟肝脏手术的切割。方法采用数字化虚拟中国人女性一号(Virtual Chinese Human Female No．1 VCH-F1)数据集中所有包含肝脏的连续图像,首先对组织切片图像进行配准后从中分割提取出肝实质、肝静脉、胆管、胆囊等组织的图像信息,然后应用可视化工具包(Visualization Toolkit,VTK)三维重建,建立肝脏表面及内部结构的三维形态模型,并开发一个基于PC机和Windows平台的肝脏三维可视化演示系统。结果在肝脏三维可视化演示系统中,肝脏实体立体感强,可以通过设定肝脏及其管道系统的透明度,以及对模型的放大、缩小和上下左右不同方向的旋转,来观察肝脏及管道结构的立体形态。并可以按任意角度对虚拟的肝脏进行切割和观察切割面结构。结论利用VCH-F1数据集中肝脏图像,在VTK基础上开发的基于PC机和Windows平台的肝脏三维可视化演示系统基本达到了比较满意的程度,为今后数字化虚拟肝脏及虚拟各种肝脏手术的研究做了积极探索。     

大肝癌外科治疗时肝血流阻断的合理应用

目的 探讨较大肝癌病人外科治疗时肝血流阻断方法的合理应用及累及下腔静脉肝癌切除的可行性。方法 观察分析我科近3年47例大肝癌病人行肝切除时入肝血流阻断的不同方式对手术能否切除的影响及病人术后恢复的情况。结果 47例病人中行常规肝门阻断27例，选择性半肝血流阻断16例，综合性肝门阻断4例，全部病人手术治疗都成功切除肿瘤，手术顺利，术后无严重并发症，术后恢复良好。结论 对大肝癌病人，术前根据影像学检查资料及肝功能等级，术中熟练的切肝技术等综合因素，合理选用一种肝血流阻断法是保证手术成功，术后病人顺利恢复，提高中晚期肝癌人群疗效的关键。     

Application of three-dimensional spiral computed tomographic angiography prior to hepatectomy for hepatocellular carcinoma

A newly developed method of spiral computed tomography (CT) angiography was employed for 19 consecutive hepatocellular carcinoma (HCC) patients who underwent hepatectomy. Fine images of the intrahepatic vascular structure, portal venous branches and hepatic veins, and HCC nodules were obtained in 16 patients. A more accurate and easier understanding of the relationship between the intrahepatic vascular structure and the HCC nodules was provided by this spiral CT angiography compared with any other imaging modality.     

肝脏罕见肿瘤的诊断和治疗

目的 探讨肝脏罕见肿瘤的诊断和治疗方法.方法 回顾性分析我院2005年5月至2010年1月收治的25例肝脏罕见肿瘤患者的临床病理资料.结果 25例患者中肝局灶性结节性增生6例,肝血管平滑肌瘤、肝门部神经鞘瘤、肝左叶动脉瘤、肝胆管囊腺瘤、肝错构瘤、肝胆管绒毛状腺瘤、肝弥漫性大B细胞淋巴瘤各1例,肝血管平滑肌脂肪瘤2例,肝原发间质瘤2例,肝母细胞瘤5例,肝胚胎性肉瘤3例;术前行B超检查24例,CT检查22例,MRI检查6例,仅有3例(16.7%)检查和术后病理结果一致.术前诊断和术后病理符合5例(20%).25例均行手术切除治疗,包括半肝切除术7例,肝叶切除术7例,肝段切除术9例,肿瘤局部挖除2例.肝脏良性、低度恶性肿瘤及1例弥漫性大B细胞淋巴瘤术后无复发,5例恶性肿瘤随访中3例术后复发行再次手术切除,术后随访无复发;另2例死亡,平均术后生存期4个月.结论肝脏罕见肿瘤影像学诊断率低,手术切除是主要的治疗手段,对能切除的复发性肿瘤性病变应争取再次手术切除.     

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目的：探讨合并肝硬化的大肝癌病人行肝切除术时肝血供阻断方法的选择。方法：观察分析21例大肝癌病人行肝切除术时选用不同的入肝血流阻断对手术的影响及病人后恢复的情况。结果：21例病人中行常规肝门阻断8例,选择性半肝血流阻断11例,综合性肝门阻断2例,全部病人肿瘤均获完整切除,术手恢复良好,结论：对合并肝硬化的大肝癌病人,根据肝硬化的程度,术前肝功能等级术中探查结果等综合判断,选择一种合适的肝血流阻断法是保证手术成功,术后病人的顺利恢复的关键。     

Fibrin sealing in liver surgery

Intraoperative bleedings, postoperative hepatic insufficiency and local complications such as postoperative bleeding, biliary fistulas, liver necrosis and subphrenic absecess increase the risk of liver resection. The decisive prophylaxis of bleeding is the precise resection technique according to intrahepatic vascular structures. Fibrin sealing is suited to stop oozings and residual bleedings on the resection surface and to avoid postoperative bleedings and/or biliary fistulas from the resection surface.      

Spontaneous Regression of Inflammatory Pseudotumor of the Liver: Report of Three Cases

Inflammatory pseudotumor (IPT) of the liver is a rare benign hepatic lesion that sometimes mimics malignant tumors. An accurate diagnosis of IPT is important to avoid unnecessary surgery. We herein report three cases of IPT of the liver that spontaneously regressed and were successfully diagnosed without a surgical resection. Malignant tumors were initially suspected based on the initial imaging findings, including ultrasonography, computed tomography (CT), and magnetic resonance imaging. In particular, a delayed enhancement in the periphery of the masses was observed on dynamic CT scans, similar to the imaging results for metastatic tumors or intrahepatic cholangiocarcinomas. The serum levels of C-reactive protein were elevated in all three patients (6.6, 3.4, and 1.5 mg/dl), while the serum levels of tumor markers were almost within the normal ranges (carcinoembryonic antigen, <5 ng/ml; carbohydrate antigen 19-9, 201, 3, and 14 U/ml). Serial repeated imaging studies over the course of a month showed the spontaneous regression of the hepatic tumors, thus enabling us to make a diagnosis of IPT without a surgical resection. A percutaneous biopsy confirmed the histology in one case. The regression of tumors on repeated images should play a key role in making an accurate diagnosis of IPT.     

Blunt injury to intrahepatic vena cava and hepatic veins with survival

Injuries to the intrahepatic vena cava and hepatic veins are extremely lethal, particularly when caused by blunt trauma. Repair of the vena cava and hepatic veins often will require liver resection before adequate exposure can be obtained. To prevent lethal hemorrhage during resection and vascular repair, total vascular isolation of the liver may be necessary. Anoxic injury under these circumstances may be minimized by local hypothermia. The two patients reported here were successfully treated by direct suture of the vascular injuries without hepatic resection; however, vascular isolation was utilized in one patient.     

SurgiCase 5.0在肝脏外科中的临床应用

目的:探讨医学影像软件SurgiCase 5.0在肝脏外科中的应用价值。方法:收集近半年来收治的10例原发性肝癌患者的128排螺旋CT扫描图象。将CT断层图象文件导入SurgiCase 5.0中进行三维重建。利用所得的肝癌三维模型设计手术方案,并与术中结果对比。结果:10例模型可视化效果满意,可以任意转换视角,清晰显示肝肿瘤及其与肝内管道的空间关系,且与术中所见基本匹配。10例肝癌患者经软件所测预计肝脏切除体积为(490.10±185.87)mL;实际肝脏切除体积平均值为(464.40±169.51)mL,误差率7.1%,两值呈高度正相关(r=0.993,P<0.01)。结论:SurgiCase 5.0可为复杂肝癌切除提供术前参考,有利于正确选择手术方案并降低手术风险。     

3D打印技术在精准肝切除术前评估的应用

目的:探讨医学3D打印技术在精准肝切除术前评估的应用价值。方法:回顾性分析2016年1月—2016年12月在宁夏医科大学总医院肝胆外科7例复杂性肝脏肿瘤患者临床资料。其中男5例,女2例,平均年龄55岁。患者术前经上腹部增强CT扫描,使用三维可视化软件(MI-3DVS)进行三维重建,导入3D打印机,打印出1:1肝脏物理模型,分析肝脏解剖、进行术前模拟,确定手术方案。结果:全部患者的肝脏3D模型能清晰显示肝内脉管系统、肝脏及肿瘤组织解剖形态、肿瘤与肝内血管结构毗邻关系,计算出肝脏平均体积为(1 872.2±753.7)mL,肝脏肿瘤体积中位数为316.96 mL。根据3D打印结果,1例患者因肿瘤侵犯门静脉不适宜外科手术,建议行经肝动脉化疗栓塞术,其余6例均行精准肝切除,实际手术过程与术前手术规划完全符合(6/6),无围手术期期死亡。结论:医学3D打印技术可应用于肝脏肿瘤的手术规划,在精准肝切除的术前评估有一定的指导意义。     

Does the novel PET/CT imaging modality impact on the treatment of patients with metastatic colorectal cancer of the liver?

OBJECTIVE: To compare the diagnostic value of contrast-enhanced CT (ceCT) and 2-[18-F]-fluoro-2-deoxyglucose-PET/CT in patients with metastatic colorectal cancer to the liver. BACKGROUND: Despite preoperative evaluation with ceCT, the tumor load in patients with metastatic colorectal cancer to the liver is often underestimated. Positron emission tomography (PET) has been used in combination with the ceCT to improve identification of intra- and extrahepatic tumors in these patients. We compared ceCT and a novel fused PET/CT technique in patients evaluated for liver resection for metastatic colorectal cancer. METHODS: Patients evaluated for resection of liver metastases from colorectal cancer were entered into a prospective database. Each patient received a ceCT and a PET/CT, and both examinations were evaluated independently by a radiologist/nuclear medicine physician without the knowledge of the results of other diagnostic techniques. The sensitivity and the specificity of both tests regarding the detection of intrahepatic tumor load, extra/hepatic metastases, and local recurrence at the colorectal site were determined. The main end point of the study was to assess the impact of the PET/CT findings on the therapeutic strategy. RESULTS: Seventy-six patients with a median age of 63 years were included in the study. ceCT and PET/CT provided comparable findings for the detection of intrahepatic metastases with a sensitivity of 95% and 91%, respectively. However, PET/CT was superior in establishing the diagnosis of intrahepatic recurrences in patients with prior hepatectomy (specificity 50% vs. 100%, P = 0.04). Local recurrences at the primary colo-rectal resection site were detected by ceCT and PET/CT with a sensitivity of 53% and 93%, respectively (P = 0.03). Extrahepatic disease was missed in the ceCT in one third of the cases (sensitivity 64%), whereas PET/CT failed to detect extrahepatic lesions in only 11% of the cases (sensitivity 89%) (P = 0.02). New findings in the PET/CT resulted in a change in the therapeutic strategy in 21% of the patients. CONCLUSION: PET/CT and ceCT provide similar information regarding hepatic metastases of colorectal cancer, whereas PET/CT is superior to ceCT for the detection of recurrent intrahepatic tumors after hepatectomy, extrahepatic metastases, and local recurrence at the site of the initial colorectal surgery. We now routinely perform PET/CT on all patients being evaluated for liver resection for metastatic colorectal cancer.     

Virtuelle Operationsplanung in der Leberchirurgie

The operability of a liver tumour depends on its three-dimensional relation to the intrahepatic vascular trees which define autonomously functioning liver (sub-)segments. The aim of our study was to establish a computer-based three-dimensional volumetric operation planning system for the liver. METHODS: Using data from routine helical CT scans the three tissue subclasses of liver parenchyma, liver vessels and liver tumour were segmented semiautomatically. A dedicated segmenting tool was established using region growing algorithms in combination with an "intelligent" border finder. Visualisation is performed by the "Heidelberg Raytracer". The vascular trees are visualised as 3D graphs. Pseudoconnections between portal and hepatic venous trees are separated automatically. Security margins are calculated and the system presents a virtual resection proposal. RESULTS: The 3D anatomy of the liver can be visualised in high quality resulting in good depth perception. Security margins are demonstrated. Dependent liver parenchyma can be recognized automatically on the basis of the vascular trees. The system offers a individualised resection proposal including the tumour, security margin and dependent liver parenchyma. CONCLUSION: Three-dimensional presentation of the individual liver anatomy of a given patient facilitates the perception of the pathology. Virtual reality combined with artificial intelligence allows calculation of complete resection protocols, which can be quantified and modified interactively. This will make operation planning more objective; patient selection may be improved, and in cases of difficult tumour localisation different resection strategies may be tested. Thus virtual reality in liver surgery will improve teaching, surgical training and planning. It may lead to improved surgical care.     

活体部分肝移植可视化仿真手术的研究

目的 研究三维可视化仿真手术技术在活体部分肝移植外科中的应用价值.方法 利用2例胆道结石患者的肝脏64排螺旋CT扫描数据集,将所收集的数据导入自主研发的医学图像处理软件进行程序分割、配准和三维重建,重建出的肝脏及其管道模型均以STL格式输出,然后导入到FreeForm Modeling System进行修饰和平滑.利用系统的力反馈设备PHANToM进行活体部分肝移植手术的仿真研究.结果 重建的肝脏模型具有肝脏、肝动脉、肝静脉、门静脉和胆道系统,形态逼真,立体感强;肝脏可视化后,肝脏内部管道空间立体感强,肝动脉、肝静脉、门静脉和肝胆管的分布、行程以及相互关系明晰.在可视化手术系统中,使用力反馈设备PHANToM操纵手术刀,仿真活体部分肝移植的手术过程,其结果符合临床手术的效果.结论 可视化的肝脏重建模型立体、逼真,有利于肝移植手术方案的合理设计;肝移植术前的手术设计和可视化演示可提高手术效果、降低手术风险及减少手术并发症.