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 Table of Contents  
CONSENSUS
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 57-65

Expert consensus on precise diagnosis and treatment of complicated liver tumor guided by three-dimensional visualization technology


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Date of Web Publication18-Sep-2017

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/digm.digm_16_17

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  Abstract 


The three-dimensional (3D) visualization technology in liver tumor could offer decision-making support to preoperative diagnosis, individualized surgical planning, and choosing an operative approach. In addition, the hepatic 3D printing helps to realize the leapfrog development from 3D images to 3D physical models and provides better guidance of the precise surgery of complicated liver tumors. To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of complicated liver tumors, Chinese experts in relevant fields were organized by Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee to formulate this expert consensus.

Keywords: Complicated liver tumor, simulation surgery, surgical planning, three dimensional visualization, three dimensional printing


How to cite this article:
Chinese Society of Digital Medicine, Chinese Research Hospital Association of Digital Surgery Committee. Expert consensus on precise diagnosis and treatment of complicated liver tumor guided by three-dimensional visualization technology. Digit Med 2017;3:57-65

How to cite this URL:
Chinese Society of Digital Medicine, Chinese Research Hospital Association of Digital Surgery Committee. Expert consensus on precise diagnosis and treatment of complicated liver tumor guided by three-dimensional visualization technology. Digit Med [serial online] 2017 [cited 2017 Dec 15];3:57-65. Available from: http://www.digitmedicine.com/text.asp?2017/3/2/57/215025

Address for correspondence: Dr. Chihua Fang, Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510 282, Guangdong Province, China. E.mail: fangch_dr@126.com





  Introduction Top


The three-dimensional (3D) visualization technology in liver tumor is defined as a tool used to display, describe, and explain the 3D anatomical and morphological characteristics of liver tumors. The morphology and spatial distribution of the liver, biliary tract system, blood vessels, pathological tissues, and other objectives are precisely accounted for through computer image processing techniques such as data analysis, imaging fusion, segmentation, and visualization with the aid of computed tomography/magnetic resonance imaging (CT/MRI) images. It is intuitive, accurate and fast to identify the objects visually; therefore, it will offer decision-making support to preoperative diagnosis, individualized surgical planning, and choosing an operative approach.

In the past, the clinical diagnostic imaging methods of liver tumors were mainly ultrasonography, CT, MRI, and so on. Surgeons could perform nonrepresentational 3D cognition based on two-dimensional (2D) images by right of their experience. Due to the limitation and nondeterminacy of experience, especially to the diagnosis and preoperative planning of the surgical procedure, it is hard to perform an accurate assessment, leading to a relatively high incidence of postoperative complications. With the development of CT scanning technique, more distinct and enormous image datasets of liver tumors are available. Thus, large amounts of diagnostic information can be obtained to promote the research of the 3D visualization technology in liver tumors. The traditional 2D diagnostic mode of liver tumors was gradually changed by 3D visualization technology. In addition, the hepatic 3D printing helps to realize the leapfrog development from 3D images to 3D physical models and provides better guidance of the precise surgery of complicated liver tumors.

Currently, there are different understandings of complicated liver tumors. The relatively common understanding includes: (1) centrally located hepatocellular carcinoma spread to the porta hepatis; (2) there are many variations in pipe systems inside the liver; (3) intrahepatic vascular systems are deformed by compression due to the large size of the liver tumor; (4) hepatic malignancy with tumor thrombus exists in inferior vena cava and/or right atrium; (5) the patients with giant tumor regardless of its characters need to undergo extended hepatectomy; and (6) liver tumors encroached on section I, section VIII or other sections need to undergo complicated hepatectomy.[1],[2],[3] To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of complicated liver tumors, Chinese experts in relevant fields were organized by Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee to formulate this expert consensus.


  The Collection of High Quality Ct Images of Complicated Liver Tumors Top


The setting of scanning parameters and data storage of CT images (64-slice helical CT, for example): conventional supine position is chosen for plain scan from head to foot. The range is from the top of diaphragm to the inferior margin of the liver. The scanning condition is 120 kV and 250 mAs. The detector combinations are 0.625 × 64, the slice thickness is 5mm, the interval is 5mm and the screw pitch is 0.984. The time for one revolution of bulb tube is 0.5 s. The delayed scan of arterial phase is 20–25 s and the delayed scan of portal phase is 50–55 s. These image data are put into CT postprocessing workstation after the scan and the disk is burned to store the three-phase of data (plain, arterial, and portal phases).[4]

Recommendation

Surgeons should work together with radiologists and radiographers to optimize the scanning parameter based on the location, vessels adjacent to/invaded by liver tumors, and specific circumstances of hospital CT performance. The high quality triple-phase helical CT data are the foundation for building a 3D visualization evaluation model.


  The Establishment of Three-dimensional Visualization Liver and Vascular Models of Complicated Liver Tumors Top


Individualized three-dimensional visualization arterial classification

The incidence of hepatic artery variation is about 45%. Michels et al. divided them into 10 types.[5] For type I, common hepatic artery is from coeliac trunk artery. For type II, left hepatic artery is from left gastric artery. For type III, right hepatic artery is from superior mesenteric artery. For type IV, left hepatic artery is from left gastric artery and right hepatic artery is from superior mesenteric artery. For type V, accessory left hepatic artery is from left gastric artery. For type VI, accessory right hepatic artery is from superior mesenteric artery. For type VII, accessory left hepatic artery is from left gastric artery and accessory right hepatic artery is from superior mesenteric artery. For type VIII, accessory left hepatic artery is from left gastric artery, and right hepatic artery is from superior mesenteric artery/left hepatic artery is from left gastric artery and accessory right hepatic artery is from superior mesenteric artery. For type IX, common hepatic artery is from superior mesenteric artery. For type X, common hepatic artery is from left gastric artery.

Recommendation

For patients with complicated liver tumors who need to underwent hepatectomy, comprehending these variations through 3D visualization analysis of hepatic artery according to Michels' classifications is crucial to clinical diagnosis, interventional therapy, and guiding precise surgery.

Individualized three-dimensional visualization portal vein classification

The variation of portal vein is also common,[6] which can be classified into five types according to the analysis by 3D visualization technology. (1) Normal type: the main portal vein is divided into left and right branches in porta hepatis [Figure 1]a. (2) Type I variation: the main portal vein is divided into left, right anterior and right posterior branches which looks like a trident [Figure 1]b. (3) Type II variation: the main portal vein sends out the right posterior branch and then goes upward to divide into left and right anterior branches [Figure 1]c. (4) Type III variation: the right portal vein is divided into anterior and posterior branches horizontally [Figure 1]d. (5) Type IV variation: the horizontal part of left portal vein is missing. (6) Specific variation: the left portal vein is from right anterior branch [Figure 1]e.
Figure 1: Portal vein classification based on three-dimensional visualization technology (a) normal type (b) Type I variation (c) Type II variation (d) Type III variation (e) Specific variation RA: Right anterior RP: Right posterior LT: Left

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Recommendation

For patients with complicated liver tumors who need to undergo hepatectomy, portal vein classification based on 3D visualization technology is recommended to comprehend their vessels running, variation and relationship with tumors.

Individualized three-dimensional visualization portal vein classification

In hepatic surgery, the vascular control of hepatic vein is crucial to the entire procedure. It is important to summarize the character of hepatic vein and identify the variations to reserve normal hepatic tissues to the greatest extent. The classification of hepatic vein based on 3D visualization technology is based on the research by Nakamura et al.[7] The variation of inferior right hepatic vein, hepatic segment IV and VIII veins are more valuable for hepatic surgery [Figure 2].
Figure 2: Hepatic vein classification based on three-dimensional visualization technology. (a) Segment IV vein is from left hepatic vein. (b) Segment IV vein and umbilical vein are from left hepatic vein. (c) Segment IV vein is from middle hepatic vein. (d) Segment IV vein and umbilical vein are from middle hepatic vein. (e) Segment IV vein is from inferior vena cava. (f) Inferior right hepatic vein flows into inferior vena cava (posterior view)

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Recommendation

The classification of hepatic vein based on 3D visualization technology is needed, especially for the variation of inferior right hepatic vein, hepatic segment IV and VIII veins, when making the surgical planning.


  The Establishment and Classification of Three-dimensional Visualization Models for Centrally Located Liver Tumor Top


Centrally located liver tumor is mainly in segments I, IV, V, and VIII. Due to its special location and involvement with the important intrahepatic vascular system, this kind of hepatectomy is very difficult and risky.[8],[9] The traditional surgical procedure is left/right hemihepatectomy or trisegmentectomy, which remove 60%–80% liver volume, causing a high risk of massive intraoperative hemorrhage and postoperative liver failure. When performing mesohepatectomy, it is important to make individualized surgical planning to reserve more liver parenchyma. Centrally located liver tumor can be divided into five types based on its location, relationship with intrahepatic vascular system and the segments to be removed through 3D visualization technology.[10] Each type needs a specific operation method.

Type I

The tumor is located in the liver parenchyma of segments V, VIII, or both [Figure 3]a. They are characterized by their close proximity to or even direct violation of the adjacent portal vein. They do not adhere to or compress the right hepatic vein trunk. Complete excision of these lesions is required in the resection of segments V, VIII ± partial irregular resection of segment IV.
Figure 3: Classification of centrally located liver tumor based on three-dimensional visualization technology (a) Type I (b) Type II (c) Type III (d) Type IV (e) Type V. MHV: Middle hepatic vein, IVC: Inferior vena cava, LHV: Left hepatic vein, LPV: Left portal vein, RHV: Right hepatic vein, RAPV: Right anterior portal vein

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Type II

The tumor is located in the liver parenchyma of segments IVa, IVb, or both. It is characterized by its proximity to or even direct violation of the left hepatic vein trunk [Figure 3]b. In addition, it does not adhere to or compress the left hepatic vein trunk. The solution is to completely resect segments IVa, IVb ± partial irregular resection of the right anterior section.

Type III

The tumor occupies the most liver parenchyma of segments IV, V, and VIII [Figure 3]c. These lesions are characterized by their wide and deep invasion of the parenchyma, or their proximity to the middle hepatic vein. They are close to or invade some branches of portal vein, but do not adhere to or compress the right/left hepatic vein trunk. The solution is to completely resect segments IVa, IVb± partial irregular resection of segments V, VIII [narrow margin mesohepatectomy, [Figure 4]. In addition, if the liver function is normal, enough liver can be reserved. These lesions require mesohepatectomy [resection of segments IV, V, and VIII ± I, [Figure 5].
Figure 4: Patient with centrally located liver tumor belonging to classification III underwent narrow margin mesohepatectomy (a) three-dimensional visualization image (b) three-dimensional printing physical model (c) Actual surgical procedure

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Figure 5: Patient with centrally located liver tumor belonging to classification III underwent standardized mesohepatectomy (a) three-dimensional visualization image. (b) Actual surgical procedure. (c) Actual surgical procedure

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Type IV

This type of liver tumor occupies the most liver parenchyma of segments IV, V, and VIII [Figure 3]d. The lesions are characterized by their close proximity to, or a direct violation of, the left/right portal vein trunk or the left/right hepatic vein. In addition, if the liver function is normal, enough liver can be reserved. These lesions require a traditional operative procedure including left/right trisegmentectomy. If the reserved liver parenchyma is not large enough, but the portal and hepatic vein scan meet the required conditions, narrow margin left/right trisegmentectomy can be performed under this circumstance.

Type V

This type of liver tumor occupies the superficial liver parenchyma of segments IV, V and VIII [Figure 3]e. The lesions are not close to either the portal branch or the hepatic vein. Under such circumstances, irregular resection of liver parenchyma is an option and the incisal margin should be negative.

Recommendation

Classification and surgical planning of centrally located liver tumor based on 3D visualization technology is important to reserve more liver parenchyma and reach the goal of precise hepatectomy.


  Evaluation System of Surgery Simulation After Building the Three-dimensional Visualization Model Top


Individualized three-dimensional visualization liver segment

Currently, the Couinaud liver segment method, which is used in clinical settings, benefits from the results of in vitro liver cast study and the coincidence rate of crowd is only 20%–30%. If digital medical technology can be used in the research of liver segment, individualized segmental partition can be performed based on blood topological relation of each patient and shown in 3D visualization images. Therefore, each functional segment is supplied by portal vein and drained by hepatic vein.[11] There could be 7, 9, or 10 segments when intrahepatic vascular system variation occurs. Regular and irregular liver segment could be precisely divided using3D visualization technology. Therefore, individualization can be truly achieved and it is more practical and accurate.

Recommendation

For patients with complicated liver tumors who need to receive hepatectomy, individualized liver segmentation should be done before the surgery.

Individualized three-dimensional visualization liver volume calculation

Currently, there are three approaches to calculate the liver volume: (1) the computational formula of liver volume;[12] (2) manual volumetry based on sectional data such as CT images;[13] (3) 3D reconstruction of CT images, namely calculating the liver volume by 3D reconstruction based on the principle of voxel.[14] When the software is developed, the sum of dots (voxel) of the volume is calculated. Drainage and standard block methods are used to measure and proofread the volume. Total volume divided by total dots makes the volume of each dot, and then the standard for the volume represented by each dot is obtained. The results show that calculating the liver volume by 3D visualization technology is accurate.[15]

Recommendation

For patients with complicated liver tumors who need to receive hepatectomy, individualized liver volumetry should be done before the surgery.

Preoperative evaluation and simulation surgery

The 3D model is imported into the simulation surgical system when individualized liver segmentation and volumetry are completed. Different kinds of simulation surgery are performed according to tumor location and its relationship with intrahepatic vascular systems through simulation surgical instruments and force feedback devices in virtual environment created by the system.

Recommendation

Preoperative virtual surgery simulation could be performed when the hospital has the right equipment. In recent years, for patients who will have insufficient remnant liver volume in the future and who cannot receive major hepatectomy, partial associating liver partition and portal vein ligation for staged hepatectomy or portal vein embolization could be an option.


  The Application of 3d Visualization Hepatic 3d Printing in Complicated Hepatectomy Top


The hepatic 3D printing can still be used after the 3D reconstruction. The 3D printing model can truly represent the characteristics of intracorporeal organ and further approximate the reality based on 3D visualization technology [Figure 6]. The advantages are described as follow: (1) the location, size and shape of tumor are faithfully represented and observed, and the relationship between the tumor and vascular systems can be observed from different perspectives. (2) Real-time indirect navigation could be provided during the surgery to recognize and localize vital positions quickly.
Figure 6: Complicated hepatectomy guided by three-dimensional printing technology. (a) A three-dimensional printing model of rare vascular aberration (segment IV portal vein is from right anterior branch) (b) Type III variation of portal vein and the inferior right hepatic vein flowing into inferior vena cava (posterior view)

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Recommendation

For patients with complicated liver tumors, preoperative hepatic 3D printing model could be used to guide the actual surgical procedure if the hospital has appropriate equipment.


  Preoperative Surgical Planning of Precise and Complicated Hepatectomy Guided by 3d Visualization Top


Preoperative surgical planning of complicated hepatectomy in the presence of variation of hepatic vein

It is hard for CT and MRI to detect the variation of hepatic vein while 3D visualization technology can display individualized traits of hepatic vein visually. The anatomy and variation of segment IV and inferior right hepatic vein are important in right hemihepatectomy. The segment IV vein mainly flows into left and middle hepatic vein. [Figure 7] and [Figure 8] show that the segment IV hepatic vein flows into left hepatic vein, and right hemihepatectomy which removes the middle hepatic vein is safe under this circumstance.[16]
Figure 7: The tumor is located in the right liver, segment IV hepatic vein flows into the left hepatic vein, so segment IV will not be affected when the middle hepatic vein is removed

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Figure 8: Right hemihepatectomy which removes middle hepatic vein is chosen in the actual operation

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Recommendation

For patients with liver tumors who need to undergo right hemihepatectomy, 3D visualization technology can help to recognize the segment IV and inferior right hepatic veins.

Preoperative surgical planning of complicated hepatectomy in the presence variation of portal vein

The 3D visualization technology plays an important role in accurate display of the course of the portal vein and identification of the variation preoperatively to formulate a reasonable surgical planning based on the classification of variation to reduce the vice damage of vascular systems and reserve more hepatic tissues, such as, (1) the narrow-margin right hemihepatectomy with type III variation of portal vein [Figure 9]; (2) The specific variation of portal vein. The segment IV portal vein is from the right anterior branch. When the right hemihepatectomy is performed, the trunk of right portal vein needs to be cut off, and it will lead to blood supply insufficiency of segment IV. On this occasion, narrow-margin right hemihepatectomy is a better option. Segment 4 portal vein from the right anterior branch is separated and protected, and then the narrow-margin right hemihepatectomy is performed [Figure 10].
Figure 9: Narrow margin right hemihepatectomy is chosen for patients with type III variation of portal vein

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Figure 10: The preoperative surgical planning and actual operation of complicated hepatectomy with specific variation of portal vein. (a) The blood supplement of segment IV from right portal vein is shown in three-dimensional visualization image (black arrow). (b) Temporary blocking the trunk of right portal vein shows that the ischemia area is around falciform ligament (black arrow is the boundary of right three sections), the yellow arrow is the actual boundary of left and right liver. The narrow margin-right hemihepatectomy is performed and some part of segment V and VIII is reserved

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Recommendation

For patients with complicated liver tumors who need to undergo hepatectomy, preoperative 3D visualization analysis is necessary. It will help to recognize the variation of portal vein and its classification, and together with liver segmentation and volume calculation, it will help to choose a reasonable surgical planning.

For patients with insufficient liver volume after hepatectomy, narrow-margin hepatectomy is a choice

The narrow margin right hemihepatectomy is referring to an innovative hepatectomy which should meet the following conditions when dealing with patients with right hepatic tumor(s). (1) Posthepatectomy liver failure will occur if standard right hemihepatectomy is performed. (2) Parts of section V and VIII are reserved after partial right hepatectomy is done. (3) The right portal veins belong to the normal type and the residual hepatic cross-section conforms to the requirements of the guidelines. (4) The stub of portal vein of sections VI and VII or right posterior portal vein can be seen after the hepatectomy. This is the narrow-margin right hemihepatectomy, which is a kind of complicated hepatectomy. 3D visualization analysis can show clearly the vessels that need to be disconnected or reserved and can reserve enough residual liver. Therefore, the safety of patient will be ensured to the greatest extent when the tumors are removed [Figure 11].
Figure 11: The narrow-margin right hemihepatectomy guided by three-dimensional visualization technology. (a) Preoperative surgical planning based on three-dimensional visualization technology: the white arrow is the boundary of left and right liver, the black arrow is the boundary of narrow margin right hemihepatectomy. (b) In the actual procedure, the yellow arrow is the boundary of narrow-margin right hemihepatectomy and the white arrow is the boundary of left and right liver. (c) The route of segments V and VIII portal vein and nub of segment VI and VII are observed in the dissected plane after removing the tumor

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Recommendation

For patients with insufficient liver volume after right hemihepatectomy, the narrow-margin right hemihepatectomy is a choice.


  The Guiding of Other Treatments for Liver Tumors by Three-dimensional Visualization Technology Top


Transcatheter arterial chemoembolazition (TACE)[17] is an important treatment among other treatments for liver tumors. The trunk and fine branches of supplying vessels of tumor, especially the variation of hepatic artery, can be shown clearly in 3D visualization images to provide a precise 3D "vessel-tumor" model. The 3D visualization technology can provide the operative approach of percutaneous radiofrequency ablation and cryocare knife, and accurately predict crushed region of electrode probe during the operation. For targeted drug and immunological therapy,[18] the 3D observation of the development of tumor during the treatment continues can be realized, and the digital treatment and curative effect can be analyzed.

Recommendation

For patients undergoing TACE, radiofrequency ablation and cryocare knife treatment, understanding the hepatic artery through 3D visualization technology is recommended.


  The Guiding of the Postoperative Re-examination by Three-dimensional Visualization Technology Top


No matter what treatment methods are chosen for patients with hepatocellular carcinoma, the regular reexamination is necessary. Ultrasonography,[19] hepatic tri-phase incremental helical CT and Gd-EOB-DTPA-enhanced MR imaging[20] are used to dynamically track the prognosis effect. If neoplasm recurs, reevaluation can be performed to provide 3D anatomical evidence for treatment.

Recommendation

Ultrasonography, hepatic triphase incremental helical CT and Gd-EOB-DTPA-enhanced MR imaging are regularly performed. Comparing the 3D reconstruction results with preoperative 3D images may help dynamic comprehending of tumor recurrence.


  Epilogue Top


In clinical setting, hepatectomy for patients with complicated liver tumors poses a challenge. Currently, in the treatment of complicated liver tumors, the advantage and significance of 3D visualization technology is gradually paid more attention and it is popularized step by step. During the surgical operation, the real-time guidance by ultrasonography is also important to enhance the accuracy. When dealing with patients undergoing hepatectomy, effective protection of liver function during perioperative period (e.g., the use of ulinastatin[21]) is as important as operation technique. In conclusion, for patients with complicated liver tumors who need to undergo hepatectomy, and who are tentatively diagnosed by ultrasonography, CT and so on, hepatic 3D visualization analysis of the target lesion is recommended because of the high risk and difficulty in technique. Hepatic 3D printing evaluation can be used, if the hospital has the right equipment. It is significant to make this technology play a supporting role in precise preoperative diagnosis, precise operation during the surgery, and obtaining the best rehabilitation efficacy.

The Committee of Expert Consensus on Precise Diagnosis and Treatment of Complicated Liver Tumor Guided by Three-dimensional Visualization Technology:

Validated by: Wan Yee Lau

Directors of the Committee: Shaoxiang Zhang, Hongchi Jiang, Lijian Liang

Participants: Susu Bao, Xiujun Cai, Xiangjun Cai, Yajin Chen, Guihua Chen, Shuqun Cheng, Chaoliu Dai, Chihua Fang, Jia Fan, Xiaoping Geng, Hongchi Jiang, YiJiang, Weidong Jia, Dexing Kong, Lijian Liang, Jun Liu, Yingbin Liu, Lianxin Liu, Qiping Lu, Jingfeng Liu, Jinrui Ou, Baogang Peng, Zhiwei Quan, Chengyi Sun, Liguo Tian, Xiaoyu Yin, Yang Yang, Shaoxiang Zhang, Xuewen Zhang, Bixiang Zhang, Taiping Zhang, Weiping Zhou, Xuting Zhi

Byliners: Chihua Fang1,2, Wei Cai1,2, Qiping Lu3

1Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China,

2The Clinical Engineering and Technological Research Center of Digital Medicine of Guangdong Province, Guangzhou 510282, China,

3Department of General Surgery, Wuhan General Hospital of Guangzhou Military, Wuhan 430064, China.

Financial support and sponsorship

The National High Technology Research and Development Program of China (863 Program) (Grant No. 2006AA02Z346 and 2012AA021105), the National Key R&D Program (No. 2016YFC0106500), the NSFC-GD Union Foundation (No. U1401254), the Major Instrument Project of National Natural Science Fund (No. 81627805), the Natural Science Foundation of Guangdong Province, China (Grant No. 6200171), the Science and Technology Program of Guangdong Province, China (Grant No. 2012A080203013), the Science and Technology Plan Project of Guangzhou (No. 201604020144).

Conflicts of interest

There are no conflicts of interest.

This article is based on a study first reported in the Chin J Prac Surg, 2017(01):53-59.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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