Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
Surg Endosc. 2024 Mar;38(3):1379-1389. doi: 10.1007/s00464-023-10612-x. Epub 2023 Dec 26.
Image-guidance promises to make complex situations in liver interventions safer. Clinical success is limited by intraoperative organ motion due to ventilation and surgical manipulation. The aim was to assess influence of different ventilatory and operative states on liver motion in an experimental model.
Liver motion due to ventilation (expiration, middle, and full inspiration) and operative state (native, laparotomy, and pneumoperitoneum) was assessed in a live porcine model (n = 10). Computed tomography (CT)-scans were taken for each pig for each possible combination of factors. Liver motion was measured by the vectors between predefined landmarks along the hepatic vein tree between CT scans after image segmentation.
Liver position changed significantly with ventilation. Peripheral regions of the liver showed significantly higher motion (maximal Euclidean motion 17.9 ± 2.7 mm) than central regions (maximal Euclidean motion 12.6 ± 2.1 mm, p < 0.001) across all operative states. The total average motion measured 11.6 ± 0.7 mm (p < 0.001). Between the operative states, the position of the liver changed the most from native state to pneumoperitoneum (14.6 ± 0.9 mm, p < 0.001). From native state to laparotomy comparatively, the displacement averaged 9.8 ± 1.2 mm (p < 0.001). With pneumoperitoneum, the breath-dependent liver motion was significantly reduced when compared to other modalities. Liver motion due to ventilation was 7.7 ± 0.6 mm during pneumoperitoneum, 13.9 ± 1.1 mm with laparotomy, and 13.5 ± 1.4 mm in the native state (p < 0.001 in all cases).
Ventilation and application of pneumoperitoneum caused significant changes in liver position. Liver motion was reduced but clearly measurable during pneumoperitoneum. Intraoperative guidance/navigation systems should therefore account for ventilation and intraoperative changes of liver position and peripheral deformation.
影像引导有望使肝脏介入治疗中的复杂情况更加安全。由于通气和手术操作导致的术中器官运动，临床成功率受到限制。目的是在实验模型中评估不同通气和手术状态对肝脏运动的影响。
在活体猪模型中（n=10）评估通气（呼气、中间和完全吸气）和手术状态（自然状态、剖腹术和气腹）引起的肝脏运动。为每只猪的每种可能的因素组合拍摄计算机断层扫描（CT）扫描。通过在 CT 扫描后对肝静脉树之间的预定义标记进行图像分割来测量肝运动。
肝脏位置随通气显著变化。与中央区域（最大欧几里得运动 12.6±2.1mm，p<0.001）相比，肝脏的外周区域显示出更高的运动（最大欧几里得运动 17.9±2.7mm），所有手术状态均如此。测量的总平均运动为 11.6±0.7mm（p<0.001）。在手术状态之间，从自然状态到气腹，肝脏的位置变化最大（14.6±0.9mm，p<0.001）。与剖腹术相比，从自然状态到剖腹术的平均位移为 9.8±1.2mm（p<0.001）。与其他方式相比，气腹时呼吸依赖性肝运动明显减少。在气腹时，通气引起的肝运动为 7.7±0.6mm，在剖腹术时为 13.9±1.1mm，在自然状态时为 13.5±1.4mm（所有情况下均 p<0.001）。
通气和气腹的应用导致肝脏位置发生显著变化。气腹时肝运动虽减少，但仍可明显测量。因此，术中引导/导航系统应考虑通气和肝脏位置及外周变形的术中变化。
