Zhao Dong, Zhang Kang-Jun, Fang Tai-Shi, Yan Xu, Jin Xin, Liang Zi-Ming, Tang Jian-Xin, Xie Lin-Jie
Department of Liver Surgery and Organ Transplantation Center, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China.
World J Gastrointest Surg. 2022 Oct 27;14(10):1141-1149. doi: 10.4240/wjgs.v14.i10.1141.
Split liver transplantation (SLT) is a complex procedure. The left-lateral and right tri-segment splits are the most common surgical approaches and are based on the Couinaud liver segmentation theory. Notably, the liver surface following right tri-segment splits may exhibit different degrees of ischemic changes related to the destruction of the local portal vein blood flow topology. There is currently no consensus on preoperative evaluation and predictive strategy for hepatic segmental necrosis after SLT.
To investigate the application of the topological approach in liver segmentation based on 3D visualization technology in the surgical planning of SLT.
Clinical data of 10 recipients and 5 donors who underwent SLT at Shenzhen Third People's Hospital from January 2020 to January 2021 were retrospectively analyzed. Before surgery, all the donors were subjected to 3D modeling and evaluation. Based on the 3D-reconstructed models, the liver splitting procedure was simulated using the liver segmentation system described by Couinaud and a blood flow topology liver segmentation (BFTLS) method. In addition, the volume of the liver was also quantified. Statistical indexes mainly included the hepatic vasculature and expected volume of split grafts evaluated by 3D models, the actual liver volume, and the ischemia state of the hepatic segments during the actual surgery.
Among the 5 cases of split liver surgery, the liver was split into a left-lateral segment and right tri-segment in 4 cases, while 1 case was split using the left and right half liver splitting. All operations were successfully implemented according to the preoperative plan. According to Couinaud liver segmentation system and BFTLS methods, the volume of the left lateral segment was 359.00 ± 101.57 mL and 367.75 ± 99.73 mL, respectively, while that measured during the actual surgery was 397.50 ± 37.97 mL. The volume of segment IV (the portion of ischemic liver lobes) allocated to the right tri-segment was 136.31 ± 86.10 mL, as determined using the topological approach to liver segmentation. However, during the actual surgical intervention, ischemia of the right tri-segment section was observed in 4 cases, including 1 case of necrosis and bile leakage, with an ischemic liver volume of 238.7 mL.
3D visualization technology can guide the preoperative planning of SLT and improve accuracy during the intervention. The simulated operation based on 3D visualization of blood flow topology may be useful to predict the degree of ischemia in the liver segment and provide a reference for determining whether the ischemic liver tissue should be removed during the surgery.
劈离式肝移植（SLT）是一种复杂的手术。左半肝和右三叶劈离是最常见的手术方式，均基于库氏肝段划分理论。值得注意的是，右三叶劈离后的肝表面可能会出现与局部门静脉血流拓扑结构破坏相关的不同程度缺血改变。目前对于SLT术后肝段坏死的术前评估及预测策略尚无共识。
探讨基于三维可视化技术的拓扑学方法在SLT手术规划中肝段划分的应用。
回顾性分析2020年1月至2021年1月在深圳市第三人民医院接受SLT的10例受者及5例供者的临床资料。术前对所有供者进行三维建模及评估。基于三维重建模型，采用库氏肝段划分系统及血流拓扑肝段划分（BFTLS）方法模拟肝劈离过程。此外，还对肝脏体积进行了量化。统计指标主要包括三维模型评估的肝血管系统及预期劈离移植物体积、实际肝脏体积以及实际手术中肝段的缺血状态。
5例劈离式肝手术中，4例肝脏被劈分为左半肝和右三叶，1例采用左右半肝劈离。所有手术均按术前规划成功实施。根据库氏肝段划分系统及BFTLS方法，左半肝体积分别为359.00±101.57 mL和367.75±99.73 mL，而实际手术中测得的体积为397.50±37.97 mL。采用拓扑学肝段划分方法确定，分配至右三叶的IV段（缺血肝叶部分）体积为136.31±86.10 mL。然而，在实际手术干预中，4例观察到右三叶部分缺血，其中1例出现坏死及胆漏，缺血肝体积为238.7 mL。
三维可视化技术可指导SLT的术前规划并提高手术中的准确性。基于血流拓扑三维可视化的模拟手术可能有助于预测肝段缺血程度，并为术中确定是否切除缺血肝组织提供参考。
