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CONSENSUS
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 108-114

Expert consensus on precise diagnosis and treatment of hepatolithiasis guided by three-dimensional visualization technology


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Date of Web Publication7-Dec-2017

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/digm.digm_28_17

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  Abstract 

The three-dimensional (3D) visualization technology in hepatolithiasis could offer decision-making support to preoperative diagnosis, individualized surgical planning, and choosing operative approach. To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of hepatolithiasis, Chinese experts in relevant fields were organized by the Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee to formulate this expert consensus.

Keywords: Hepatolithiasis, simulation surgery, targeted lithotrity, three-dimensional printing, three-dimensional visualization


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 hepatolithiasis guided by three-dimensional visualization technology. Digit Med 2017;3:108-14

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 hepatolithiasis guided by three-dimensional visualization technology. Digit Med [serial online] 2017 [cited 2017 Dec 16];3:108-14. Available from: http://www.digitmedicine.com/text.asp?2017/3/3/108/220127

Address for correspondence:
Prof. Chihua Fang,
Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
E.mail: fangch_dr@126.com



  Introduction Top


The three-dimensional (3D) visualization technology in hepatolithiasis is defined as a tool used to display, describe, and explain the 3D anatomical and morphological characteristics of hepatolithiasis. The morphology and spatial distribution of the liver, biliary tract system, blood vessels, calculus, and other objects 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 operative approach.

To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of hepatolithiasis, Chinese experts in relevant fields were organized by the Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee to formulate this expert consensus.


  Preoperative Imaging Diagnosis of Hepatolithiasis Top


There are some limitations of hepatolithiasis imaging diagnostic methods mainly including B-ultrasound, CT, MRI, magnetic resonance imaging pancreatic and endoscopic retrograde pancreatic angiography (ERCP).[1],[2] Because the bile in the bile duct is scarce or the contrast agent through the vascular route cannot directly display the bile duct, the above imaging diagnostic methods cannot accurately cover the distribution and location of stones, the location of bile duct stricture, and the indication of bile duct tree. Although ERCP and percutaneous transhepatic cholangiography have made up for this, they are invasive testing methods and are likely to have serious complications. In the past 10 years, with the development of digital medical technology, 3D visualization of the liver and biliary tract and 3D printing technology have appeared successively, which provided a new method for preoperative accurate assessment of hepatolithiasis. 3D visualization model can display the location, size, shape, and distribution of the stones in the liver, the stenosis site, length, and degree of the bile duct, the expansion/stenosis of bile duct, and the spatial anatomical relationship of the portal vein, hepatic artery, and hepatic vein clearly and stereoscopically.[3],[4] The 3D visualization technology has changed the treatment mode of 2D diagnosis in hepatolithiasis and played an important role in reducing the postoperative stone residual rate and the stone recurrence rate.

Recommendation

After diagnosis of hepatolithiasis by B-ultrasound, a 3D visualization technology was recommended.


  The Collection of High-Quality Computed Tomographic Images of Hepatolithiasis Top


After diagnosis of hepatolithiasis by B-ultrasound, the image data of abdominal CT enhancement were collected regularly. The accuracy of the 3D visualization model of hepatolithiasis was directly affected by the quality of CT image data of the four phases: precontrast phase, arterial phase, portal vein phase, and hepatic venous phase.

Recommendation

Surgeons should work together with radiologists and radiographers to optimize the scanning parameter based on the location, expansion/stenosis of the bile duct, 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 Models of Hepatolithiasis Top


The thin-layer CT data were processed by the image workstation, and the 3D visualization software system was imported and reconstructed. By regulating liver transparency, the liver and hepatic artery, the hepatic vein, and the first, second, and third branches of the portal vein were shown. The narrow biliary tract and the first–four expansion bile duct were displayed. The size, shape, and distribution of calculi were also displayed. Through the rotation observation of the model, a clear understanding of the spatial relationship between each pipeline structure is presented.[5]

Recommendation

There are many software for 3D visualization research in clinic settings. Most of them can work on a single personal computer and are recommended to be used according to the equipment condition.


  Individualized Three-Dimensional Visualization Vessel Classification Top


The liver, bile duct, calculi, and intrahepatic blood vessels were observed and analyzed based on the 3D visualization images of the liver, vascularization, abdominal vessels, and surrounding organs. For patients with hepatolithiasis who had no liver atrophy, hypertrophy, or biliary cirrhosis, 3D visualization analysis of hepatic artery was based on the Michels' classifications and that of hepatic vein was based on the Nakamura' classifications. 3D visualization analysis of hepatic portal vein was as follows: (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 the left portal vein is missing. (6) Specific variation: The left portal vein is from the 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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For patients with hepatolithiasis of the presence of liver atrophy, hypertrophy, or biliary cirrhosis, the hepatic vasculature changes in pathology. The 3D visualization of hepatic vasculature is important for selecting the surgical method and reducing the complications and risks of the operation for these mentioned above.[6],[7]

Recommendation

For patients with hepatolithiasis who need to undergo hepatectomy, the 3D visualization model was analyzed before operation to find the various vascular structures of the liver dynamically and comprehensively, which was beneficial to guide the development of a reasonable surgical plan.


  Individualized Three-Dimensional Visualization Liver Segment And Liver Volume Calculation Top


There are two purposes for liver segmentation and volume calculation in hepatolithiasis. The first is to locate the stone site accurately and guide the accurate targeted lithotripsy and the lithotomy. The second is to guide the accurate liver resection through preoperative virtual simulation surgery and selection of reasonable schemes for patients who need to undergo liver resection. The liver segmentation and volume calculation can be obtained by referring to “The expert consensus on precise diagnosis and treatment of complicated liver tumor guided by 3D visualization technology.”

Recommendation

3D visualization liver segment and liver volume calculation are significant for guiding surgical treatment before operation.


  Three-Dimensional Visualization Clinical Diagnosis of Hepatolithiasis Top


To facilitate the surgical treatment of patients with hepatolithiasis, the clinical diagnosis of hepatolithiasis was classified into three types: (1) patients with hepatolithiasis receiving surgical treatment for the first time; (2) patients who underwent surgery for hepatolithiasis previously; and (3) patients with biliary cirrhosis caused by hepatolithiasis.

In the 3D visualization model, the stereoscopic morphology and the mutual relationship of the “intrahepatic biliary tree” and “vascular tree,” the size and location of the calculi in the hepatic biliary duct, the stenosis degree and scope of the bile duct, the distribution of blood vessels, atrophy or hypertrophy of the liver, and the presence of atrophy of variation were clearly displayed. Stone distribution location (location, L), bile duct stenosis (stenosis, S), bile duct distention (distention, D), cirrhosis of the liver (cirrhosis, C), and other factors should be considered in clinical digitized diagnosis of the hepatolithiasis. For example, hepatolithiasis (LII, LVI, LVII, SII, SVI, SVII, DII, DVI, DVII, C) showed that the calculi were located in segments II, VI, and VII and also showed bile duct stricture of segments II, VI, VII, distal bile duct expansion, and cirrhosis of the liver. This digital diagnosis helps surgeons to develop more reasonable surgical options.[8]

Recommendation

The 3D visualization technology can be used to make surgeons understand the distribution of stones in the lesions of the bile ducts of the liver. It is conducive to formulating more rational scheme of surgical treatment.


  Preoperative Planning And Virtual Simulation Surgery Top


The 3D visualization system was used to conduct preoperative planning and virtual simulation surgery [Figure 2] and [Figure 3].
Figure 2: The diagnosis of hepatolithiasis determined by three-dimensional visualization model. (a) Three-dimensional visualization model showed the location of stone, stenosis and distention of the bile duct and the relationship of the portal venous. (b) Transparent bile duct of three-dimensional visualization model showed the distribution, size, morphology of the stone and the portal vein relationship. (c) Transparent liver of three-dimensional visualization model showed the distribution of calculi in the liver. (d) Transparent biliary system of three-dimensional visualization model showed the position of the stone in the liver and the stenosis of the left hepatic bile duct

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Figure 3: Virtual simulation surgery conducted by three-dimensional visualization technology. (a) Three-dimensional visualization model showed the stenosis of the left hepatic duct accurately. (b) Transparent liver of three-dimensional visualization model showed the position of calculi, biliary tract, portal vein and hepatic vein. (c) The virtual simulation surgery of left liver resection. (d) The residual liver was showed in the virtual simulation surgery

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The virtual simulation surgery system had the advantages of interactive operation and repeatability, which could simulate and predict the complicated and dangerous situations in actual operation. Through the simulation of different operation schemes, the surgeons could compare its advantages and disadvantages and make a reasonable individualized operation plan for the patient with hepatolithiasis.[9]

Recommendation

For patients with hepatolithiasis, preoperative virtual simulation surgery could be used to guide the actual surgical procedure if the hospital has appropriate equipment.


  Three-Dimensional Printing of Visualized Three-Dimensional Liver in the Diagnosis and Treatment of Complex Hepatolithiasis Top


After the reconstruction of 3D visualization, 3D printing can restore the true in vivo characteristics of human liver, making further approximation of reality based on 3D visualization [Figure 4]. Its advantages include (1) the 3D printing can display the location, size, and shape of stones and the relationship of vessels through physical model. (2) The 3D printing can provide a direct real-time navigation during the operation.[10],[11]
Figure 4: Three-dimensional printing model for complicated hepatolithiasis. Deep blue: Hepatic vein; Red: Hepatic artery; Pale blue: Portal vein; Green: Dilated bile duct; White: Stone

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Recommendation

If possible, 3D printing can be performed before surgery for indirect intraoperative guidance in patients with complex hepatolithiasis or hepatolithiasis with biliary cirrhosis who will undergo liver transplantation.


  Precise Treatment of Hepatolithiasis Guided by Three-Dimensional Visualization Technology Top


Hepatectomy is a “gold standard” for treating hepatolithiasis, but liver resection is conditional. Because of the development of minimally invasive technology, especially digital minimally invasive technology, treatment of hepatolithiasis had changed to some extent.[12]

Open hepatectomy combined with cholangioscopy targeting lithotripsy and lithotomy guided by three-dimensional visualization technology

For patients with abdominal cavity adhesion caused by previous abdominal surgery, severe stenosis or transposition of hilar bile duct that need surgery, and liver atrophy of liver segment or region, if the hospital does not have the technology of laparoscopic resection of liver segment or region, hepatectomy combined with cholangioscopy targeting lithotripsy and lithotomy guided by 3D visualization technology can be performed [Figure 5].[3],[13],[14]
Figure 5: Open surgery combined with cholangioscopy targeting lithotripsy and lithotomy guided by three-dimensional visualization technology. (a) Three-dimensional visualization model showed the complicated bile duct stenosis of the right hepatic bile duct, right anterior bile duct and right posterior bile duct; the left hepatic duct is relatively narrow. (b) Actual complicated bile duct stenosis was observed. (c) Biliary duct stenosis plasty was performed. (d) Barometric lithotripsy was performed

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Laparoscopic hepatectomy combined with cholangioscopy targeting lithotripsy and lithotomy guided by three-dimensional visualization technology

For patients with hepatolithiasis combined with stenosis and/or distention of the bile duct, with no biliary cirrhosis, and receiving surgery for the first time, laparoscopic hepatectomy combined with cholangioscopy targeting lithotripsy and lithotomy guided by 3D visualization technology can be performed [Figure 6].[9],[15],[16]
Figure 6: Laparoscopy combined with cholangioscopy targeting lithotripsy and lithotomy guided by three-dimensional visualization technology. (a) Three-dimensional visualization technology showed distribution of calculi, biliary strictures and relationship of blood vessels. (b) Laparoscopic surgery guided by three-dimensional visualization technology. (c) Barometric lithotripsy. (d) Removal of the stones

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Cholangioscopy targeting lithotripsy and lithotomy though the fistula guided by three-dimensional visualization technology

As long as there was a fistula, cholangioscopy targeting lithotripsy and lithotomy though the fistula guided by 3D visualization technology can be adopted. Since most of irrigation water enters the intestines through the lower common bile duct and  Sphincter of Oddi More Details, surgeons can choose the phased operation [Figure 7].
Figure 7: Cholangioscopy targeting lithotripsy and lithotomy though the fistula guided by three-dimensional visualization technology. (a) Three-dimensional visualization technology showed distribution of calculi, tube position and sinus running. (b) Open surgery combined with cholangioscopy targeting lithotripsy and lithotomy guided by three-dimensional visualization technology. (c) Barometric lithotripsy. (d) Postoperative imaging showed no residual stones

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Percutaneous transhepatic cholangioscopic lithotripsy guided by three-dimensional visualization technology

The steps of percutaneous transhepatic cholangioscopic lithotripsy conducted by B-ultrasound were as follows: (1) 3D visualization technology guided the percutaneous transhepatic biliary drainage. The fistula tract should be expanded 1 time after 1 week and expanded to around 16F in 2 weeks. (2) The 3D visualization technology guided cholangioscopy targeting lithotripsy and lithotomy [Figure 7]. 3D visualized liver model can carry out overall observation to target puncture, avoid bile duct tearing, and damage hepatic vein and portal vein [Figure 8].[16],[17],[18] For elder patients with hepatolithiasis, or patients with hepatolithiasis combined with suppurative cholangitis, or patients with hepatolithiasis who cannot tolerate complex surgery, percutaneous transhepatic cholangioscopic lithotripsy guided by 3D visualization technology can be adopted.
Figure 8: Percutaneous transhepatic cholangioscopic lithotripsy guided by three-dimensional visualization technology. (a) Three-dimensional visualization showed liver segmentation and calculi, which guided the selection of the needle. (b) Percutaneous transhepatic cholangioscopic lithotripsy guided by three-dimensional visualization technology. (c) Intraoperative C arm examination to see if the puncture tube was still in the bile duct. (d) Barometric lithotripsy

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Operation for patients with hepatolithiasis combined with biliary cirrhosis guided by three-dimensional visualization technology

Hepatolithiasis combined with biliary cirrhosis often needs to be treated by various surgical procedures, but the operation is difficult and risky. It is necessary to design an individual bile duct stone surgery plan.[19] The corresponding surgical procedures or liver transplantation should be selected according to the patient's Child-Pugh classification of liver function, surgeon's experience, equipment condition, and 3D visual evaluation results.

Liver transplantation guided by three-dimensional visualization technology

Liver transplantation should be carried out in the final stage of hepatolithiasis,[19],[20],[21] Because hepatic artery variation is common, for living donor liver transplantation, 3D visualization of recipient hepatic artery and donor hepatic artery should be performed before operation.

Recommendation

According to the 3D visualization results of hepatolithiasis, combined with the liver function of patients and the experience of surgeons, the corresponding surgical methods can be selected.


  Postoperative Re-Examination Top


In either way, the placed “T” tube is treated according to the need for staging treatment. The biliary support tube should be treated according to the staging, surgical needs, and timing of support decisions. 3D visualization technology was used to evaluate the effect after direct cholangiography or CT enhanced scan. In patients receiving staging lithotripsy and lithotomy though the fistula, the protection of the support tube or T tube should be strengthened.

Recommendation

3D visualization technology can be used to evaluate the effect after direct cholangiography or CT enhanced scan.

In clinical practice, the diagnosis and treatment of hepatolithiasis have always been a difficult and hot issue in biliary surgery. At present, 3D visualization technology can clearly display the location, size, and distribution of stones and the location, length, and extent of bile duct stenosis and guide the implementation of precise surgery. Its technical advantages and significance have received increasing attention and are being gradually popularized. For the patients who are initially diagnosed with hepatolithiasis by B-ultrasound, CT, etc., and need to receive resection of liver region or segment, 3D visualization analysis of the target lesions should be performed to support preoperative accurate diagnosis, intraoperative precise surgery, and recovery of patients.

The committee of Expert consensus on precise diagnosis and treatment of hepatolithiasis guided by three-dimensional visualization technology:

Validated by Head Judgement: Wan Yee Lau

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

Participants Discussants: Susu Bao, Xiujun Cai, Xiangjun Cai, Yajin Chen, Guihua Chen, Shuqun Cheng,

Chaoliu Dai, Chihua Fang, Jia Fan, Xiaoping Geng,

Hongchi Jiang, Yi Jiang, 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 Fang 1,2, Wei Cai 1,2, Qiping Lu 3,

Zhaoshan Fang 1,2

1 Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China,2 The Clinical Engineering and Technological Research Center of Digital Medicine of Guangdong Province, Guangzhou 510282, China,3 Department of General Surgery, Wuhan General Hospital of Guangzhou Military, Wuhan 430064, China.

This article is based on the study first reported in Chinese Journal of Practical Surgery in 2017 (Volume 37, Issue 1, pages 60-66).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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 and 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.

 
  References Top

1.
Li G, Fang CH, Fan YF, Wu TC, Zhong SZ. A comparative study of the diagnostic accuracy of the medical image three-dimensional visualization system, MRCP, CT and US in hepatolithiasis. Hepatogastroenterology 2014;61:1901-7.  Back to cited text no. 1
    
2.
Li HY, Zhou SJ, Li M, Xiong D, Singh A, Guo QX, et al. Diagnosis and cure experience of hepatolithiasis-associated intrahepatic cholangiocarcinoma in 66 patients. Asian Pac J Cancer Prev 2012;13:725-9.  Back to cited text no. 2
    
3.
Fang CH, Liu J, Fan YF, Yang J, Xiang N, Zeng N, et al. Outcomes of hepatectomy for hepatolithiasis based on 3-dimensional reconstruction technique. J Am Coll Surg 2013;217:280-8.  Back to cited text no. 3
    
4.
Fang CH, Xie AW, Chen ML, Huang YP, Lu CM, Li XF, et al. Application of a visible simulation surgery technique in preoperation planning for intrahepatic calculi. World J Surg 2010;34:327-35.  Back to cited text no. 4
    
5.
Xie A, Fang C, Huang Y, Fan Y, Pan J, Peng F, et al. Application of three-dimensional reconstruction and visible simulation technique in reoperation of hepatolithiasis. J Gastroenterol Hepatol 2013;28:248-54.  Back to cited text no. 5
    
6.
Dong CC, Fang CH, Wu TC, Cai W, Fan YF, Yang J, et al. Management complicated hepatolithiasis with operative rigid choledochoscope guided by computed tomography (CT)-based 3D reconstruction technique. Hepatogastroenterology 2014;61:1556-62.  Back to cited text no. 6
    
7.
Wu TC, Fang CH, Liu WY, Cai W, Fan YF, Yang J, et al. 3D reconstruction aids surgery for complicated hepatolithiasis. Hepatogastroenterology 2014;61:613-22.  Back to cited text no. 7
    
8.
Fan YF. The Study of Clinical Application with three Dimensional Technology in Precise Diagnosis and Treatment of Hepatolithus. Guang Zhou: Southern Medical University; 2011.  Back to cited text no. 8
    
9.
Fang CH, Li G, Wang P, Fan YF, Zhong SZ. Computer-aided rigid choledochoscopy lithotripsy for hepatolithiasis. J Surg Res 2015;195:105-12.  Back to cited text no. 9
    
10.
Fang CH. Minimally invasive digital technology: A new edge tool for the diagnosis and treatment of hepatolithiasis. Digit Med 2016;2:1-5.  Back to cited text no. 10
  [Full text]  
11.
Fang CH, Fang ZS, Cai W. Establishment and value of three-dimensional visualization diagnosis platform in the treatment of hepatolithiasis. Chin J Pract Surg 2015;35:974-8.  Back to cited text no. 11
    
12.
Fang CH, Xiang N. Value of digital minimally invasive technology in diagnosis and treatment of hepatolithiasis. Chin J Pract Surg 2016;36:272-7.  Back to cited text no. 12
    
13.
Xiang N, Fang C. Application of hepatic segment resection combined with rigid choledochoscope in the treatment of complex hepatolithiasis guided by three-dimensional visualization technology. Zhonghua Wai Ke Za Zhi 2015;53:335-9.  Back to cited text no. 13
    
14.
Ye X, Ni K, Zhou X, Xie K, Hong X. Laparoscopic versus open left hemihepatectomy for hepatolithiasis. J Surg Res 2015;199:402-6.  Back to cited text no. 14
    
15.
Professional Committee of Minimally Invasive Surgeons, Surgeons Branch of Chinese Medical Doctor Association. Expert consensus on laparoscopic treatment of hepatolithiasis (2013 edition). Chin J Dig Surg 2013;12:1-5.  Back to cited text no. 15
    
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Fang C, Liu W, Fan Y, Yang J, Xiang N, Zeng N, et al. Applied rigid choledochoscope and pneumatic lithotripsy in targeting treatment of hepatolithiasis guided by three-dimensional visualization technology. Zhonghua Wai Ke Za Zhi 2014;52:117-21.  Back to cited text no. 16
    
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Wang P, Sun B, Huang B, Xie J, Liu Y, Zhu C, et al. Comparison between percutaneous transhepatic rigid cholangioscopic lithotripsy and conventional percutaneous transhepatic cholangioscopic surgery for hepatolithiasis treatment. Surg Laparosc Endosc Percutan Tech 2016;26:54-9.  Back to cited text no. 17
    
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Kow AW, Wang B, Wong D, Sundeep PJ, Chan CY, Ho CK, et al. Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen. Surgeon 2011;9:88-94.  Back to cited text no. 18
    
19.
Liao CX, Zhou J, Yang DH. Surgical treatments for hepatolithiasis complicated with biliary cirrhosis and portal hypertension Electronic Edition. Chin J Hepat Surg 2015;1:24-6.  Back to cited text no. 19
    
20.
Fang CH, Li XF, Li Z, Fan YF, Lu CM, Huang YP, et al. Application of a medical image processing system in liver transplantation. Hepatobiliary Pancreat Dis Int 2010;9:370-5.  Back to cited text no. 20
    
21.
Gu JY, Xia Q. Surgical interventions for hepatolithiasis in liver transplantation era. Chin J Pract Surg 2016;36:302-4, 315.  Back to cited text no. 21
    


    Figures

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



 

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