Methods
tumor, bleeding, biliary fistulas, intrahepatic lesions, intrahepatic bile duct dilatation
BILIARY FISTULAS, TUMOR, LIVER, BLEEDING
The control group was given conventional surgical treatment with general anesthesia by tracheal intubation, and the surgical position was supine, with routine disinfection and surgical towel. The tumor tissue was completely exposed within the field of vision, the first and second hepatic hilum was blocked, the large blood vessels and the hepatic hilum were clamped, the peripheral ligaments such as the hepatic round ligament and the sickle ligament were separated, and resection was performed at a position about 2 cm from the edge of the tumor tissue, from superficial to deep, from inside to outside. The residual blood vessels and bile ducts are ligated or sutured. The wound is rinsed and observed for biliary fistulas and bleeding, followed by hemostasis, placement of an abdominal drain and closure of the abdomen.The study group was given precision hepatectomy.(1) CT examination: A 64-row spiral CT machine from GE, USA, with a layer thickness of 1.25-5 mm, scanned from the top of the diaphragm to the lower edge of the liver, and divided into a plain phase, an arterial phase and a portal phase. Patient CT data is collected and stored in Digital Image in Medicine (DICOM) format for data transfer via PACS system or data retention on disk.(2) Three-dimensional reconstruction of the liver: The CT data of all patients are obtained in the IQQA-Liver, a three-dimensional liver reconstruction software produced by EDDA, USA. The system automatically extracts the image information of the liver parenchyma, lesions, portal veins and parts of the hepatic veins, reconstructs the spatial structure of the liver parenchyma and the intrahepatic ducts, segments the intrahepatic lesions, and the three-dimensional reconstruction shows their spatial shape, size, parts and the interrelationship between them and the intrahepatic ducts. The 3D reconstruction shows the spatial shape, size, parts and interrelationships with the intrahepatic ducts. The 3D and 2D fusion tools included in the software are used to check the authenticity of the image, to dynamically observe the reconstructed model in the 3D plane, and to manually outline and modify the few reconstruction discrepancies to remove irrelevant parts. For patients with intrahepatic bile duct dilatation, the bile ducts were identified, extracted and reconstructed, while the posterior inferior vena cava was completely reconstructed by hand. The model is rotated in the 3D plane to view the lesion from multiple angles, and the software automatically generates an image report of all the data processed by the reconstruction and saves the dynamic data in AVI video format using the video recording function. (3) Liver volume measurement: In the three-dimensional liver reconstruction system, the whole liver volume, lesion volume, pre-resection liver volume and remaining liver volume of the virtual surgical model, the distance between the lesion and each duct, the internal diameter of each duct in the section, and other parameters were measured in real time using the measurement tools brought by the system, and the measured data were generated and saved as text reports. The whole liver volume, focal volume, pre-operative pre-resected liver volume and remaining liver volume were also measured in 49 patients using our PACS system to obtain two-dimensional measurements of liver volume in all cases.(4) Virtual surgical design: The 3D reconstructed model of the liver of 49 patients was observed from multiple angles in 3D space, the relationship between the lesion and the hepatic vein, portal vein and bile duct was clarified, the invasion of the first and second hepatic hilum and the posterior inferior vena cava was analyzed, the tumor resection boundary was set by applying the tumor safety boundary range tool with reference to each measurement data, and finally the 3D reconstructed model was simulated to be cut by using the software liver space cutting tool. The patient’s liver volume and the percentage of the whole liver were measured in real time, and all resection options were analyzed and compared to assess whether the volume of the remaining liver could meet the postoperative compensations according to the patient’s lesion volume and the invasion of important structures in the adjacent liver. The design of the individualized virtual surgical resection is completed, and different surgical options are compared, selected and optimized to finalize the surgical plan and guide the clinical procedure.(5)Tracheal intubation general anesthesia, take the supine position, the right subcostal incision into the abdomen, first explore and then use the B-ultrasound and preoperative 3D virtual planning to determine the pre-cut line, selectively block the hepatic artery and portal vein branches of the liver segment to which the tumor belongs, and cut off the liver parenchyma along the boundary of the liver segment, as far as possible to ensure complete resection of the tumor while reducing the damage to its surrounding vascular structure, free the tumor tissue along the ischemic line by ultrasonic scalpel combined with clamp method, ligate or suture the broken blood vessels and bile ducts, confirm the section to stop bleeding, and use argon to spray the section.