| Background:Primary liver cancer has been one of the main research directions of oncologists and surgeons because of its large population and high mortality.Anatomic hepatectomy is an important treatment for primary liver cancer.Due to the complex vascular structure in liver,vascular metastasis becomes an important mode of intrahepatic metastasis for primary liver cancer.Anatomical hepatectomy not only excises the tumor part and the tumorbearing liver tissue,but also excises the vascular system in this area.In particular,the research data and related literature in the last ten years support the increasing number of anatomical hepatectomy,which is related to the maturity of this surgical method and the addition of important techniques.The tumor could grow anywhere in the liver.The right anterior region of the liver is the most characteristic site of primary hepatocellular carcinoma.First of all,based on the blood vessels of the liver,it is determined that the right anterior area provides the blood supply channel for the right anterior area and connects with the blood vessels in the liver.Secondly,in the aspect of portal vein,there are many kinds of portal veins in the right anterior region of the liver.To perform anatomic hepatectomy in the right anterior region of the liver,it is necessary to clearly evaluate its blood vessels and do a good job of anatomical segmentation at this location.The theory of "five leaves and eight valves" put forward by Counaud is the most widely accepted classical liver anatomy model.However,in recent years,due to the progress of 3D image display technology and surgical methods,the simple use of a single section to segment the liver has been limited.Due to the complex classification of portal vein and hepatic vein,there are many variations in the blood vessels supplying traditional liver segments.The traditional segmentation mode reflects the characteristics of the anatomical position of the blood vessels inside the liver,But it is not consistent with the blood circulation of the liver.Therefore,the river basin theory of the liver has gradually come into people’s vision.In the river basin theory,the blood vessels of the liver are no longer just "trunks" and "branches" with spatial position relationship,but just like rivers.Both the anatomical spatial position relationship and the blood supply and blood return of the region through which it flows reflect the functional characteristics.By introducing the concept of watershed analysis,we have a better understanding of the segmentation of the right anterior region of the liver,and 3D visualization technology is used to accurately depict the blood vessels in the liver to find the topological relationship between the hepatic vein and the portal vein.,realize the simulation watershed analysis and individual liver segmentation,achieve more accurate ananatomical hepatectomy,and minimize the residual liver congestion area.To evaluate the volume of the remaining liver to a greater extent,and reduce the occurrence of complications.Objective of the study:(1)Three-dimensional visualization imaging of the veins and lobes of the right anterior part of the liver,and identify important data such as vascular variation,vascular diameter,location and variation of important nodes(2)Use 3D visualization technology to evaluate the portal vein and hepatic vein involved in tumor.Through the topological relationship between them,realize simulation basin calculation and individualized liver segmentation,plan the excision scope and calculate the pre-excision volume;The clinical significance of the traditional Couinaud segment,the segmented segment based on portal vein analysis and the segmented segment assessment of portal vein combined with hepatic vein basin will be compared(3)Combined with the surgical practice,According to the situation of portal vein and liver and pelvis,the intraoperative anatomy was evaluated comprehensively,and the operative area needed during the operation was estimated.and preexcision volume will be compared with the actual situation,so as to explore the clinical significance of vascular evaluation and basin analysis in this way Methods:(1)The portal vein and hepatic vein of the right anterior part of the liver were analyzed by 3D image display technique.In this study,a total of 100 patients from the first Hospital of Jilin University from April 2020 to October 2022 were examined by multi-disciplinary enhanced CT,such as liver,gallbladder,pancreas and spleen.DICOM software was used for three-dimensional imaging and applied in clinic.Through the comparison of CT and 3D images,the changes of portal vein and hepatic vein were studied,and the number of hepatic veins in the branch of right anterior lobe regurgitation was calculated.The diameter of the main hepatic vein and the anatomical distance of the important nodule to its fixation.(2)Use 3D visualization technology to evaluate the portal vein and hepatic vein involved in tumor,and realize simulation basin calculation and individualized liver segmentation through topological relationship between them,plan the resection range,and calculate the pre-resection volume: The clinical significance of the traditional Couinaud segment,segmented segment based on portal vein analysis,and individualized segmented segment assessment of portal vein drainage combined with hepatic vein drainage will be exploredSixty cases of hepatocellular carcinoma in the right anterior region diagnosed for the first time in the first affiliated Middle School of Jilin University were studied retrospectively.After removing the patients with vascular and biliary invasion,the patients were divided into two groups: more than 3 cm and less than 3 cm according to the size of the tumor.Enhanced abdominal CT was performed on all patients,and the obtained images were transmitted to the abdominal cavity in the form of DICOM files,and then the intraperitoneal three-dimensional model was established by intra-abdominal CT imaging technology.At the same time,CT and 3D images are compared and processed.All patients received segmented treatment with Couinaud.individualized liver segmentation based on portal vein drainage analysis,and individualized hepatic vein combined with portal vein drainage analysis: The center lines of hepatic vein and portal vein were extracted to construct the topology structure,and the local hepatic vein drainage basin and portal vein drainage basin were reconstructed according to the scope of tumor involved blood vessels,respectively,and the scope of individualized liver resection was constructed by simulation drainage basin calculation and model fusion.The pre-excision volumes evaluated by different methods were calculated respectively for statistical comparison.(3)Combined with the actual operation,the preoperative anatomical relationship was evaluated,and the pre-excision volume was evaluated by portal vein and hepatic vein watershed analysis to compare with the actual situation,so as to explore the clinical significance of vascular assessment and watershed analysis by this methodThirteen cases of primary hepatocellular carcinoma diagnosed for the first time from April 2022 to February 2023 in the first affiliated Hospital of Jilin University were studied retrospectively.Thirteen cases of surgical treatment due to tumor invasion of artery and common bile duct were analyzed preliminarily and correspondingly.Results:(1)For the portal vein,there were five variations of portal vein(P5)going to segment V.I: the right branch of the portal vein has left and right anterior and posterior branches,one of which is a branch and bifurcates to the V segment.And the trunk formed several branches.II:generally the right branch of the portal vein is divided into the right anterior branch and the right posterior branch,while the main branch of the right anterior branch only forms the collateral branch of the VIII segment(P8),while the dorsal or ventral branch of P8 supplies the V segment collateral branch downward or forward.and there is no simple main branch of segment V;III: The main branch of the right portal vein does not send out the right anterior branch.And each has three branches,that is,the upper right anterior branch,the lower right anterior branch,the lower right posterior branch,and three separate branches.IV: P5 mainly comes from the right posterior branch of the portal vein,usually the first branch of the right posterior branch of the portal vein.V: P5 is composed of ventral branch of P8 and main branch from ventral branch of P8 to V segment.P8 is mainly composed of the ventral and dorsal rami,which are necessary,and the lateral and medial rami can be seen in some imaging data.Therefore,there are four types: I,ventral rami + dorsal rami;Type II,ventral rami + dorsal rami + medial rami;III,ventral rami + dorsal rami + lateral rami;IV: ventral rami + dorsal rami + medial rami + lateral rami.(2)For hepatic veins,the middle hepatic vein is generally composed of two intersecting herrings,and the anterior fissure vein can be seen in 56% patients showing reflux to the middle hepatic vein.The mean radius of the main middle hepatic vein is 3.81±0.52 mm,and the range of V5 v of the V segment of the middle hepatic vein is 1-5,with a median of 2.The number of V8 v branches in reflux VIII segment was 1-4,and the median was 2;the mean radius of the right hepatic vein trunk was 3.89±0.62mm;the number of V5 d branches in reflux V segment was 1-3,and the median was 1;the number of right hepatic vein flowing to V8 v segment VIII was 0-4,and the median was 1.For;The average line distance from A(the intersection of the right hepatic vein and the first foot branch of V5d)to the beginning of the Luville sulcus is 37.81 ±6.36 mm,and from B(the intersection of the middle hepatic vein and the first foot branch of V5v)to the bifurcation of the left and right branches of the portal vein is 35.52±5.84 mm.(3)For masses less than 3 cm,the lesion volume obtained by conventional Counaud profile was significantly different from that obtained by portal vein-based pelvic anatomy.For masses more than 3 cm,there was no significant difference in the amount of focus removal between the two segments during the operation.For patients with less than 3 cm,there was no significant difference.For masses more than 3 cm,the resection rate of portal vein combined with hepatic artery was significantly higher than that of portal vein combined with hepatic vein.(4)The preexcision volume predicted by the portal vein combined hepatic drainage basin analysis was significantly correlated with the actual intraoperative excision volume,and there was no significant difference between the two.Conclusions:(1)The structure of the portal vein and hepatic vein in the right anterior region is relatively diverse,and there are many different changes.The use of three-dimensional visualization technology is conducive to observation,providing morphological basis for anatomic hepatectomy,and conducive to the accurate implementation of anatomic hepatectomy.(2)The drainage basin analysis of individual liver based on 3D visualization technology has advantages.Through the study of portal blood flow,the estimated value of liver blood flow is obtained,which reflects the idea of "blood trough" theory,and has advantages compared with the traditional Couinaud segmental preoperative estimation of resection scope,especially in the case of small tumor volume.The estimated hepatectomy volume based on the comprehensive analysis of the portal vein drainage basin and the hepatic vein drainage basin is strongly correlated with the actual resection volume during the operation,which can better reflect the actual influence of the drainage area during the resection process.Therefore,how to accurately and accurately evaluate the residual liver volume plays a key role in improving the quality of life and prognosis of patients. |
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