| BackgroundThe traditional anatomical organs study aim directly at cadaveric specimens. Since they were not perfused, the internal pipesal organ collapsed, the three-dimensional conformational space of the liver changed. So the pipeline structure which we obtained was different from the structure of the living liver. With the development of modern imaging (spiral CT, MRI, etc.), hepatobiliary surgery get to a new stage. The concept of surgical treatment of liver cancer is being transformed. Many liver cancers which encroached the porta hepatis, portal vein and inferior vena cava were excised; the living donor right liver and the enlarged right liver transplantation were performed. However, it remains the king problem that the complexity and variability of liver and other organ pipe structure cause complications. Such as, postoperative bleeding. Maybe, the study of medical image visualization and virtual reality technology can solve these problems. With the chiastopic fusion and the rapid development of the computer technology, the image processing technology, the medicophysics and the medicine, the surgical diagnosis and therapy experienced great change. In these years, the computer-assisted operation system and the virtual operation system are the achievements of the rapid development of the information science applied in the medical region. The surgeons can make the operation safely, reliably and accuratly with the advanced skills. The flying development in modern science and technology has built a concrete ground for the vital studies on the three-dimensional (3D) reconstruction of hepatic duct systems in recent years. The 3D reconstruction through hispeed CT angiography conducted by Raptopouls V, et al displayed the full views of portal and hepatic veins as well as the spatial conformational relations anatomically. Consequently the portal and hepatic veins can be located and their diameters, obstructions and collateral circulations can be evaluated. Wigmore SJ et. all reconstructed liver from the scanned images by helical CT and performed the virtual surgical incision of liver to access the risk of hepatic failure after hepatic incision and reckon the incision range. The three-dimension hepatic and the virtual surgery make use of such imagery sequence as CT and MRI, so as to display a three-dimensional model of the various structures of the liver, making the hiding human organ a visible "live" three-dimensional object, namely visualization. The strengths include:1) being specifically located in certain space; 2) Being observable in structure and being measurable and available while performing various surgeries on virtual liver; 3) Enhancing the advancement of anatomical liver. In various surgeries of virtue liver, the CT or MRI examination data of specific liver cancer patients could be employed for image fusion and update. Hence the surgeons can use their computers to conduct surgical planning and test the operational process repeatly. Such computerization exercise will help surgeons to optimize the planning, ensure the surgery quality and safety, and reduce the operative complications.Part 1. Studies on the Application of Digitalization in Living-related kidney transplantationObjective1. Establishing three-dimensional model of kidney and blood vessels in the abdominal cavity, find out the characteristics variability and anatomic structure of kidney and blood vessels;2. By establishing three-dimensional model of donor and receptor's abdominal cavity, finding out it's application value of guiding clinical Living-related kidney transplantation;3. Establishing simulated operation condition of Living-related kidney transplantation, accomplished the Living-related kidney transplantation, and do research on it's guidance in the clinical operations.Methods1.Materials:(1) PHILIPS BRILLIANCE 16-slice helical CT, Image process workstation;(2) binocular tube high pressure injector;(3)computer;(4) DICOM Viewer;(5) ACDSee (6) Medical image three-dimensional visualization system;(7) FreeForm Modeling System and PHANTOM.2. Examiners:There are 5 cases of Living-related kidney transplantation from 2009.1-2010.12.5 in Guangdong No.2 provincial people's hospital. Including 3 male receptor,2 female donor, ages 45-46, average age is36.3 male donator,2 female donator, ages 46-56, average age is 53. The relations between donator and receptor is3 cases from parents given child, sons or daughters given parents none,2 cases were given by brothers or sisters, other relatives given none, wife given husband none. There are 5 cases of Donator-receptor's ABO blood type ipentity, type 0 donate type B none, type 0 donate type A none, type 0 donate type AB none. Iymphocytotoxicity cross matching result is negative. HLA matching:antigen 1 mispairing none, antigen 2 mispairing 3 cases, antigen 2 mispairing 1 case, antigen 4 mispairing one case, HLA completely mispairing none. Receptors' penel reactive antibody test:PRA>10% zero, PRA<10% 5 cases. The protopathy. Including chronic glomerulonephritis, chronic pyelonephritis, diabetic nephropathy, IgA nephropathy etc.The receptors all accept dialysis therapy.3. Collection of CT scan data:plain scan and enhanced scan on epigastrium by 16-slice helical CT were done on the examines, and the scan data was burned and stored from Mxview which is a image postprocessing workstation of PHILIPS BRILLIANCE 64-slice helical CT.4. Data transformation:The burned data was imported into personal computers. Using DICOM viewer, translate the original data format into BMP format. Adjust the size, and order the pictures with ACDSee.5. The CT data which was translated was imported into Medical image three-dimensional visualization system and made procedure segmentation and three-dimensional reconstruction, then stored on the STL format.6. Smoothing:The models of the artery, portal vein and hepatic vein were imported into Free Form Modeling System, and smoothed in the system.7. Simulated operation of kidney transplantation:After rebuilt three-dimensional model of the objects, choosing donor and receptor of the living kidney transplantation. Leading-in the data into the Free Form Modeling System and PHANTOM, reconstruct the operation condition of the living-related kidney transplantation. Operating procedure including:right/left kidney resection; kidney transplantation(right), etc.8.Clinical operation of kidney transplantation:According rebuilding the three-dimensional model and Simulated operation of kidney transplantation, doing clinical operation.Results1. Three-dimensional model's reconstructKidney, arteria renalis, venae renales were clear and perspective in the Three-dimensional model which was built by 5 donator and receptor. In 5 cases,2 have Arteria renalis variation, one have accessory renal artery variation, one have early branches, no venae renales variation. Find out one case of donator's artery three-dimensional model, find out both left and right kidney of donator have variation, left ateria renalis can be seen two branches after leaving aorta abdominalis, those were early branches. The same as left ateria renalis. Besides, left ateria renalis has a accessory renal artery; thus one case of donator's artery three-dimensional model were early branches.2. Simulated operationIn the Free Form Modeling System and PHANTOM, fictitious the operation condition of the living-related kidney transplantation. Besides, using simulated-scalpel, simulated surgical needle and simulated tissue forceps which innovated independently, completed the simulated operation of the living-related kidney transplantation. 3. Clinical operationClinically, according to the conclusion of three-dimensional rebuilt and simulated operation, the operation of living-related kidney transplantation was completely success. Donator and receptor recovered good, no obvious neopathy.Conclusion1. Three-dimensional rebuilt of the kidney and blood vessels, can be used for guiding clinical living-related kidney transplantation.2. Simulated operation of living-related kidney transplantation has important guidance in the donator receptor's vascular anastomosis.Part2. Studies on the Application of Digitalization in piggyback liver transplantationObjective1. Establishing piggyback liver transplantation for liver and blood vessels of the abdominal receptor three-dimensional model, understand the vascular anatomy of the liver and its structure and variation of characteristics;2. Through the abdominal reconstruction for three-dimensional model of the receptor and donator, study its guidance value in the clinical piggyback liver transplantation.3. To establish simulation piggyback liver transplant environment, complete piggyback liver transplantation, study it's guidance in clinical surgeries.Methods1. Materials:PHILIPS BRILLIANCE 64-slice helical CT, others is the same with part one.2. Examiners:the donor:the people who is health examination, CT showing:the liver,gallbladder, pancreas and spleen are normal; receptor:Hepatic function:ALT: 287IIU/L, AST:193IU/L, GGT:57 IIU/L, Total bilirubin:12.3μmol/l, direct bilirubin:7.2μmol/l. CT prompting:left lateral lobe of liver can be found one of the low-density video, others is not found focus of infection. Clinical diagnosis:primary liver carcinoma.3. Collection of CT scan data:plain scan and enhanced scan on epigastrium by 64-slice helical CT were done on the examines, and the scan data was burned and stored from Mxview which is a image postprocessing workstation of PHILIPS BRILLIANCE 64-slice helical CT.4. Data acquisition, data transformation, procedure segmentation, reconstruction, and smoothing are the same with part one.5. The main step of piggyback liver transplantation is the liver excision of the donor, hepatectomy of receptor, the donor implanting to the receptor.Results1. The results of 64-slice spiral CT scanFor donor,437 images of four periods are collected,372 images for receptor. All the images are good. The contrast agent for the receptor of the left branch of portal vein is filled poor, others are good.2. The results of 3D reconstructionThe abdominal 3D model is clear, realistic and seeming three-dimensional. The abdominal organs and ducts can be simulated effectively, and can be rotated randomly, magnified, decreased and made being transparency.3. Simulation surgeryIn Freeform Modeling System and its own system of Phantom force-feedback, the environment of piggyback liver transplantation was built. And using the secondary development of a simulation electric knives, simulation surgical needle and simulation tissue forceps, the simulation surgery of the piggyback liver transplantation can be operated. All the steps are in accordance with the process of clinical operations. We have a strong sense of feedback in cutting and saturation.Conclusion1. Donor and recipient anatomical structure can be seen clearly in the three-dimensional reconstruction of piggyback liver transplantation, thus can be optimized clinical surgical procedures; 2. Simulation of piggyback liver transplantation surgery can help clinicians familiar with the procedure, reduce surgical errors and improve the success rate of surgery.Part3:Studies on the Application of Digitalization in orthotopic liver transplantationObjective1. To establish orthotopic liver transplantation and three-dimensional model of abdominal blood vessels, liver and vascular anatomy. To understand the structure and variation of characteristics;2. Through the abdominal reconstruction for three-dimensional model receptor. To study its clinical orthotopic liver transplantation in the application;3. Establishing simulating orthotopic liver transplantation environment, complete the transplant in former situation. Study it's guidance in the clinical surgery.Methods1. Materials:the same with part one.2.Examiner:Liver transplantation donor:Female,33 years old, height 159cm, weight 57Kg, blood, biochemical tests were normal, CT Note:liver, gallbladder, pancreas, spleen were normal. Clinical liver disease was not found; Recipients orthotopic liver transplant:male,58 years old, height 173 cm, weight 72kg, liver function: alanine amino transferase (ALT):578IU/L,γ-glutamic acid acyl transferase (GGT): 325 IU/L, total bilirubin:35.1μmol/l, direct bilirubin:17.8μmol/l. CT Hint:right lobe of liver low-density mass, expansion of intrahepatic bile duct lesions. Alpha-fetoprotein (AFP):positive, carcinoembryonic antigen (CEA):negative. Clinical diagnosis of right-lateral segment liver bile duct carcinoma.3. Data acquisition, data transformation, procedure segment, reconstitution, smoothing is the same with part one.4. the main step of orthotopic liver transplantation are the liver excision of the donor, hepatectomy of receptor, the donor implanting to the receptor. Results1. The results of 64-slice spiral CT scanFor donor,503 images of four periods are collected,461 images for receptor. All the images are good. The contrast agent for the receptor of the left branch of portal vein is filled poor, others are good.2. The results of 3D reconstructionThe abdominal 3D model is clear, realistic and seeming three-dimensional. The abdominal organs and ducts can be simulated effectively, and can be rotated randomly, magnified, decreased and made being transparency.3. Simulation surgeryIn Freeform Modeling System and its own system of PHANToM force-feedback, the environment of piggyback liver transplantation was built. And using the secondary development of a simulation electric knives, simulation surgical needle and simulation tissue forceps, the simulation surgery of the piggyback liver transplantation can be operated. All the steps are in accordance with the process of clinical operations. We have a strong sense of feedback in cutting and saturation.Conclusion1. Three-dimensional reconstruction of the dorsal orthotopic liver transplantation donors and recipients have clearly anatomical structure, that can be optimized clinical surgical procedures;2. Simulation orthotopic liver transplantation surgery, can help clinicians familiar with the procedure, reduce surgical errors and improve the success rate of surgery.PART4:Studies on the Application of Digitalization in split liver transplantationObjectiveTo understand the process of splitting liver transplantation surgery.Methods1. Materials:the same with part one. 2. Examiners:Donor:"healthy" subjects were male,25 years old, height 170cm, weight 63Kg, liver and kidney function was normal, CT prompts the liver, gallbladder, pancreas, spleen, no abnormal clinical liver disease was not found. Receptor 1:Male,51 years old, height 165cm, weight 66Kg. Liver function:alanine amino transferase (ALT):387IU/L, aspartate aminotransferase (AST):243U/L, y-glutamic acid acyl transferase (GGT):76 IU/L; total bilirubin:112.5μmol/1, direct bilirubin:82.4μmol/l. CT:right lobe of liver with a 16×12cm of low density and found no other lesions. Alpha-fetoprotein (AFP):245.67μg/l (0～10.9μg/l), carcinoembryonic antigen (CEA):10.68ug/l (0～10μg/l). Receptor 2:Male,9 years old, height 121cm, weight 37Kg. Liver function:alanine amino transferase (ALT):127IU/L, aspartate aminotransferase (AST):67U/L, y-glutamic acid acyl transferase (GGT):19 IU/L; total bilirubin:16.3μmol/l, direct bilirubin:11.5μmol/ 1. CT:left lobe of liver with a 3×2cm of the low density and found no other lesions. Alpha-fetoprotein (AFP):24.56μg/l (0～10.9μg/l), carcinoembryonic antigen (CEA):2.45μg/l(0～10μg/l).3. Data acquisition, data transformation, procedure segment, reconstitution, smoothing is the same with part one.4. Split liver transplantationResults1. The results of 64-slice spiral CT scanFor donor,511 images of four periods are collected,427 images for receptor I, 389 images for receptorⅡ. All the images are good. The contrast agent for the receptor of the left branch of portal vein is filled poor, others are good.2. The results of 3D reconstructionThe abdominal 3D model is clear, realistic and seeming three-dimensional. The abdominal organs and ducts can be simulated effectively, and can be rotated randomly, magnified, decreased and made being transparency.3. Simulation surgeryIn Freeform Modeling System and its own system of PHANToM force-feedback, the environment of split liver transplantation was built. And using the secondary development of a simulation electric knives, simulation surgical needle and simulation tissue forceps, the simulation surgery of the split liver transplantation can be operated. All the steps are in accordance with the process of clinical operations. We have a strong sense of feedback in cutting and saturation.ConclusionSimulation surgery of Split liver transplantation is complexed, besides it's one of the most difficult surgery in the organ transplantation. Digital medicine in the split liver transplantation has a certain value.PART5:Studies on the Application of Digitalization in Combined Liver and Kidney TransplantationObjective1. Establish three-dimensional model of the abdominal cavity in the combined liver-kidney transplant, understand the structure and mutation of abdominal organs and vascular anatomy.2. Through the abdominal reconstruction for three-dimensional model receptor, study its clinical guidance in liver transplantation.3. Build simulation environment combined liver-kidney transplant, complete simulation of combined liver-kidney transplant surgery, and study its role in guiding clinical surgery.Methods1. Materials:the same with part one.2. Examiners:Donor:volunteer subjects, male,26 years old, height 168cm, weight 68Kg, blood, biochemical tests were normal, CT Note:liver, gallbladder, pancreas, spleen, kidney Dengjun no exception; Receptors:subject volunteers, female,34 years old,161cm,52Kg, blood biochemical tests were normal, CT Note:liver, gallbladder, pancreas, spleen, kidneys were normal.3. Data acquisition, data transformation, procedure segment, reconstitution, smoothing is the same with part one.4. The main step of combined liver and kidney transplantation are the liver and the kidney excision of the donor, hepatectomy of receptor, the donor implanting to the receptor.Results1 The results of 64-slice spiral CT scanFor donor,503 images of four periods are collected,861 images for receptor. All the images are good. The contrast agent for the receptor of the left branch of portal vein is filled poor, others are good.2 The results of 3D reconstructionThe abdominal 3D model is clear, realistic and seeming three-dimensional. The abdominal organs and ducts can be simulated effectively, and can be rotated randomly, magnified, decreased and made being transparency.3 Simulation surgeryIn Freeform Modeling System and its own system of PHANToM force-feedback, the environment of combined liver and kidney transplantation was built. And using the secondary, development of a simulation electric knives, simulation surgical needle and simulation tissue forceps, the simulation surgery of the combined liver and kidney transplantation can be operated. All the steps are in accordance with the process of clinical operations. We have a strong sense of feedback in cutting and saturation.Conclusion1. Three-dimensional reconstruction of the liver and kidney transplantation about the donor and recipient have clearly anatomical structure and can be optimized clinical surgical.2. Simulation of combined liver-kidney transplant surgery, can help clinicians familiar with the procedure, reduce surgical errors and improve the success rate of surgery.
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