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| REVIEW |
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| Year : 2015 | Volume
: 1
| Issue : 1 | Page : 17-22 |
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The pancreatic surgery in the era of digital medical science
Chihua Fang1, Wei Cai1, Shizhen Zhong2
1 Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University; The Clinical Engineering and Technological Research Center of Digital Medicine of Guangdong Province, Guangzhou 510282, China
2 Institute of Clinical Anatomy, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| Date of Web Publication | 30-Sep-2015 |
Correspondence Address:
Chihua Fang
Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong Province
China
 Source of Support: The National High-Tech Research and Development Projects of China (863) (2012AA021105); the National Natural Science Foundation of China (Grant No.U1401254); the Major Science and Technology Projects of Guangdong province (Grant No.2012A080203013), Conflict of Interest: None declared.  | Check |
DOI: 10.4103/2226-8561.166365
The development of science and technology not only promotes the development of the society but also has a great influence on the progress of medicine. The three-dimensional (3D) printing technology together with other digital production modes will promote the realization of the third industrial revolution. New 3D equipment and concepts brought a huge leap forward in surgery, and pancreatic surgery also benefits from this. The author has committed himself to the scientific research of 3D pancreatic surgery for decades, and applying 3D visualization technology to the diagnosis and treatment of pancreatic cancer, 3D visualization of peripancreatic vessels, resectability evaluation of the pancreatic cancer and prevention of pancreatic fistula. This article presents a new idea on the development of pancreatic surgery and introduces not only the progress in the diagnosis and treatment of pancreatic diseases in the era of digital medicine, but also the relative advantages brought about by the new equipment (such as da Vinci robotic surgical system, 3D Laparoscope). Keywords: Digital medical, pancreas, pancreatic surgery
How to cite this article:
Fang C, Cai W, Zhong S. The pancreatic surgery in the era of digital medical science. Digit Med 2015;1:17-22 |
| Introduction | |  |
With the development of surgical technique in the past century, the pancreatic surgery has entered a new era. Today in the 21st century, the trend of surgery is based on minimally invasive surgery. The computer will be a useful tool in our daily work. This will appeal a new alliance consisting of three-dimensional (3D) visualization of the body images, interventional imaging technology, endoscope, natural orifice transluminal endoscopic surgery, the da vinci robotic system, the surgical simulator of virtual site, and minimally invasive surgery.[1] The surgery will enter the digital era, so does the pancreatic surgery. In 2002, the first dataset of Chinese digital human was built successfully. This milestone means that the level of Chinese digital medicine has reached the world advanced one. In the datasets, we chose the images of the liver, biliary tract and pancreas to do the research of 3D visualization. This is the beginning of the pancreatic surgery in the era of digital medical science in our country.
| A New Approach for the Development of the Pancreatic Surgery | | |
Due to the structural characteristics of pancreas itself as well as the complicated anatomy of peripancreatic tissues and organs, pancreatic surgery is very difficult.[2],[3] The shape of the pancreas is different. Those traditional human anatomy atlases can't give an explicit explanation of the anatomy of the pancreas. The application of digital human technology in abdominal organs could be a new approach to solving the problems in the research of pancreas. Obtaining the 3D images of the pancreas is a great help to the development of pancreatic surgery, and it will make a great progress for it.[4] Nowadays, an important method to improve the ability of surgeons to diagnoze pancreatic diseases and judge the variation of pancreas shape is using the modern scientific equipment to do the 3D reconstruction of pancreas and peripancreatic tissues and organs. In order to implement accurate surgery and reduce the accidental damages during the operation, it is useful to figure out the relationship between the pancreatic tumor and peripancreatic vessle through the 3D construction.[5] However the research of peripancreatic tissues and organs is still insufficient and hence we can't accomplish the research of simulation surgery technology based on the visible human. Pancreas, dodecadactylon, common bile duct, inferior vena cava, portal vein and its branches, aortaventralis and other abdominal organs could be arbitrarily observed by 3D reconstruction. We can thus closely observe the deep structure, and both the clinical work and anatomical study were benefited from it. We can also carry out the virtual cutting of pancreas, and it is the upfront work of the pancreas virtual surgery.
| The Diagnosis and Treatment of Pancreatic Tumors in the Three-Dimensional Era | | |
The pancreatic surgery had already entered the 3D era. Or more accurately, it had already entered the 3D era of the diagnosis and treatment of pancreatic tumors.
Due to the low sensitivity and specificity for the diagnosis of pancreatic tumors, the resection rate for pancreatic tumors is not satisfying. An accurate evaluation of the resectability of pancreatic tumors is very important. It can avoid some unnecessary surgical explorations, and it will reduce pain of patients. Some pancreatic tumors were considered as unresectable on account of their atypical imaging features or imperfection of image reproduction technology, so the patients have to give up surgical treatment. About 80 patients with pancreatic or duodenal ampulla tumors undertook preoperative evaluation in Zhujiang Hospital of Southern Medical University and Southwest Hospital of the Third Military Medical University from November 2009 to August 2011. We respectively used medical image 3D visualization system (MI-3DVS) and 64-section multidetector row helical computed tomography (CT) to do the preoperative evaluation and the verification results were proved by the actual operation process to find the resectability of tumors. The accuracy of 64-section multidetector row helical CT was 82.5%, and the accuracy of of MI-3DVS was 100%. The accuracy between two groups was statistically significant.[6] It shows that the 3D visualization technology of MI has more advantages in the preoperative evaluation.
| A Three-Dimensional Visual Study of the Pancreas-Associated Vessels and Its Applications in Pancreatoduodenectomy | | |
In normal circumstances, the super-anterior and inferoanterior pancreasduodenal arteries of people converge at the head of the pancreas to form the anterior arterial arch of pancreas. Compared with other arterial arches of pancreas, the anterior arterial arch is quite small. It can't be detected by routine image examination easily. The super-posterior and inferoposterior pancreasduodenal arteries of people converge at the back of pancreas to form the posterior arterial arch of pancreas. This arterial arch is the biggest one among the arterial arches of pancreas, and it can easily be detected. According to an anatomy study, the appearance rate of dorsal pancreatic artery in the peripancreatic vessels ranges from 77.5% to 96% and its diameter is about 2 cm.[7] The major function of dorasal pancreatic artery is providing blood supply to pancreatic body and tail. There is a high appearance rate of anterior and posterior arterial arch of pancreas and its branches. The blood supply of the superior part of pancreas head is made up of super-anterior and super-posterior pancreasduodenal arteries. The blood supply of the posterior part of pancreas head is made up of posterior-anterior and posterior-posterior pancreasduodenal arteries. These two arches [Figure 1]a and [Figure 1]b have many branches to supply the dodecadactylon. It is the main blood supply of the head of pancreas and dodecadactulon. There is a close integration relationship between dodecadactylon and head of the pancreas. The blood supply of them is provided by the branches of arterial arch of pancreas and dodecadactylon under normal circumstances.[8],[9] The anterior superior pancreaticoduodenal vein enters right gastro-omental vein, and the posterior superior pancreaticoduodenal vein enters superior mesenteric vein. They together make up the anterior venous arch of the pancreatic head. The main function of the anterior venous arch of the pancreatic head is to collect blood supply of the front edge of pancreaticoduodenum. The posterior venous arch of the pancreatic head consists of super-posterior and inferoposterior pancreaticoduodenal veins. The main function of the posterior venous arch of the pancreatic head is to collect blood supply of the trailing edge of pancreaticoduodenum. Other peripancreatic venules are so small that could not be detected easily. | Figure 1: (a) The anterior artery arch of the pancreatic head. (b) The posterior artery arch of the pancreatic head
Click here to view |
In pathological status, peripancreatic vessels can be pressed by tumors, and it may cause blood reflux obstacle so that the peripancreatic venules will be extensively expanded. Thus, it can be seen that there are many important vessels around the peripancreas, and the variation of vessels isn't rare. The variation of vessels will impact the operation of pancreatic surgery. We found that the variation rate of the hepatic artery is high, and its classification is complicated.[10] If we can't find the variation before the pancreaticoduodenectomy, we may cause an accidental injury or change the surgical plan in order to perform venous reconstructions. It may cause a lot of complications such as hepatapostema, bile leakage, abdominal hemorrhage and so on.[11] If we can't detect the aberrant right hepatic artery before the operation, we may overlook the variation based on our habitual thinking. When gastroduodenal artery was severed, the right hepatic artery is the main supplier of blood for the rest of extrahepatic bile duct. So if we severed the right hepatic artery during the operation, some complications of liver will easily occurred after the operation and it may cause ischemia of the rest of extrahepatic bile duct to result in pancreatic leakage.[12],[13] Therefore, getting accurate messages of the type and orientation of the aberrant right hepatic artery can provide surgeons with more information before the operation and can help to make a decision of the surgical therapy. MI-3DVS is a wonderful system which can use sub-millimeter CT images to complete 3D reconstruction in a short time. The 3D models coming from the system that simulates the real ones, and we can use it in our routine clinical work. We performed this technique in our daily work and found 14 cases (12.3%, 14/114) with variant hepatic artery, including replaced right hepatic artery arising from superior mesenteric artery (SMA) in nine (7.9%, 9/114), replaced left hepatic artery arising from left gastric artery in two (1.8%, 2/114) and common hepatic artery arising from SMA in three (2.6%, 3/114). MI-3DVS has a high sensitivity and specificity to detect the variant hepatic artery and has an accurate rate of 100%.[14] These 3D models can be transparent and splitted from different angles to let the surgeons observe the anatomy structures more conveniently. They can also show the morphology of tumors and the relationship between tumors and important vessels. We can assess the resectability of pancreatic carcinomas and choose a reasonable operation procedure.[15],[16] So it is a useful tool and has broad application prospects in general surgery.
| The Prevention of Pancreatic Leakage in Digital Medical Era | | |
Pancreatic leakage is one of the most dangerous complications after pancreatoduodenectomy. In the past 20 years, as the surgical techniques develop, the mortality after pancreatoduodenectomy has reduced by 20%.[17],[18] But the incidence of pancreatic leakage still varies from 8% to 25% including 57% of level-B and 8% of level-C. The mortality caused by pancreatic leakage accounted for about one-fifth of the total fatality. There are many factors that can cause pancreatic leakage, and the operative procedure we chose to complete the pancreaticojejunostomy is the only controllable factor during the operation.[19] Our research team investigated the anatomical basis theory of the occurrence of pancreaticojejunostomy and created "one thread" pancreaticojejunostomy procedures in pancreaticoduodenectomy under the guidance of 3D visualization by ourselves. We performed this method in 26 patients with pancreaticoduodenectomy, and the results showed that it was a useful way to prevent pancreaticojejunostomy after pancreaticoduodenectomy.[20] The concrete operation steps as follows are: (1) The surgeon had a simulated operation before the surgery to find an appropriate position to amputate pancreas. Because everyone's situation is different, it is a necessary individual process. (2) We measured pancreatic duct's diameter on the basis of 3D images before the surgery and take them down [Figure 2]. (3) During the surgery, we can easily find the pancreatic duct after amputating pancreas. We chose an appropriate pipe support matching the pancreatic duct which was cut three or four side holes in advance. We put the pipe support into the main pancreatic duct at 5 or 6 cm and fixed them with 4-0 Vicryl line. Then we kept the pancreatic duct as center, and chose U suture method to deal with the front and back wall of stump of pancreas. The other side of the pipe support is put into the jejunum. (4) Using U suture method to deal with the pancreatic section: Keeping a distance of 0.5 cm from the pancreatic section, we used a 4-0 Prolene running through the front and back wall of pancreas to do the U suture method with interlocking and intermittent suture. We inserted from the front wall of pancreas and pulled out the needle from the back wall of pancreas. And we inserted from the back wall of pancreas and pulled out the needle from the front wall of pancreas. Then we started to tie a knot and did the same processes until finishing the suture of stump of the pancreas. The steps of "one thread" pancreaticojejunostomy procedures in pancreaticoduodenectomy: (1) After confirming the location of where to do the pancreaticojejunostomy, we used an intact 4-0 Prolene to finish the job. We put the mesenteric margin of the jejunum and the stump of pancreas close-up. From the inferior margin, we used the A-end of the suture to suture the capsula pancreatic of the inferior margin of the pancreatic stump and the back wall of seromuscular layer of jejunum. The knot was tied in the middle of the suture [Figure 3]. (2) The suture of seromuscular layer at the back wall of pancreatic enteric anastomosis: We still used A-end of the suture from a distance of 0.5 to 0.8 cm of the stump of the pancreas to suture the back wall of pancreas and seromuscular layer of jejunum together until to the superior border of the pancreatic enteric anastomosis. Each suture should be frapped and knotted with the traction suture from the superior border of the stump of pancreas [Figure 4]. (3) Cutting open the mesenteric margin of jejunum: On the basis of the distance between superior border and inferior margin of the stump of pancreas which was get from 3D measurements before the surgery, we cut open the mesenteric margin of jejunum in the corresponding site appropriately. (4) Full-thickness suture of the back wall of the pancreatic enteric anastomosis: We used B-end of the suture insert from the serosa of the jejunum at the inferior of the anastomosis and pulled out the needle from the mucosal of the jejunum. The back wall of the stump of pancreas and the back wall of the jejunum were full-thickness continuous suture from bottom to up. When we sutured the back wall of the pancreas, each stitch should surpass the U suture of the back wall of the stump of pancreas and knot with the A-end of the suture at the top of the anastomosis [Figure 5]. (5) Cutting off the other side of the pipe support in 6–8 cm and put it into the far end of jejunum. (6) Full-thickness suture of the front wall of the pancreatic enteric anastomosis: The A-end of the suture was used to full-thickness continuous suture the front wall of the stump of the pancreas and the front wall of the jejunum from up to bottom. Each stitch should surpass the U suture of the front wall of the stump of pancreas and knot with the traction suture at the bottom of the anastomosis [Figure 6]. (7) Suturing the seromuscular layer at the front wall of anastomosis: Using the B-end of the suture to continuous suture the capsula of the front wall of pancreas and seromuscular layer at the front wall of the jejunum from up to bottom. Knotting with the A-end suture was performed at the inferior part of the anastomosis [Figure 7]. | Figure 2: Measuring pancreatic duct's diameter on the basis of three-dimensional images before the surgery
Click here to view |
 | Figure 3: Using an intact 4-0 Prolene to put the mesenteric margin of the jejunum and the stump of pancreas close up
Click here to view |
 | Figure 4: Using A-end of the suture from a distance of 0.5–0.8 cm of the stump of the pancreas to suture the back wall of pancreas and seromuscular layer of jejunum together until reaching the superior border of the pancreatic enteric anastomosis
Click here to view |
 | Figure 5: Full-thickness suture of the back wall of the pancreatic enteric anastomosis
Click here to view |
 | Figure 6: Full-thickness suture of the front wall of the pancreatic enteric anastomosis
Click here to view |
 | Figure 7: Suturing the seromuscular layer at the front wall of the anastomosis
Click here to view |
We apply MI-3DVS in our daily work and find that the "one thread" pancreaticojejunostomy procedures in pancreaticoduodenectomy under the guidance of 3D visualization are meritorious. This method is convenient and causes a few damages to the pancreas. It can apply to many different types of the stump of the pancreas and the results are satisfactory. The incidence of pancreatic leakage is 7.7% after the operation, belonging to level-A. It is obviously lower than previously reported.[21] This method has many virtues such as short operation time, user-friendly control and fewer complications. So it is a useful method to prevent pancreaticojejunostomy after pancreaticoduodenectomy and worth spreading in clinical work.
| The Da Vinci Robotic Systems and Three-Dimensional Laparoscope | | |
Since 2000, surgical robots such as the da vinci robotic systems are considered as a new revolution in the history of the development of surgical. Because they have brought a whole new idea to the surgery and have an incomparable advantage in promoting accuracy, security and feasibility into a high level.[22],[23],[24],[25] At present, the application of surgical robots is the third-generation of da vinci robotic systems. It could reduce damage to the patients. It has three subsystems including a console for surgeon, a robotic arm surgical system beside the bed and a 3D imaging system. During the operation, the three seemingly independent systems are working together to ensure that the operation can be finished in a safe way. The da vinci robotic systems can use 3D high definition images to blow up the operation field for 10–15 times. The operational processes adopt a simulation system. When a surgeon is working in the console, the robotic arm could perfectly imitate the surgeon's actions at the same time. The robotic arm is more flexible than human hands and has seven different direction degrees of freedom. It can filter the tremor automatically with its own controller, so it's more stable than human hands and can show its great advantages when suturing vessels and nerves.[26] In partial pancreatectomy and pancreaticoduodenectomy, the da vinci S robotics also have an obvious advantage. According to reports in the literature,[1] 104 pancreatic surgeries were done by da vinci S robotics from 2000 to 2009, including 60 pancreaticoduodenectomies, 23 far-end pancreatectomies, three middle pancreatectomies, one total pancreatectomy and three enucleation pancreatectomies. The operative mortality was 2.20%, and the incidence of pancreatic leakage was 21.00%. Fourteen patients were converted to laparotomy, and the rate of complications was 26.00%.
Scientific and technological progress has also brought about a high-end equipment–3D laparoscope–to us. Compared with the traditional two-dimensional laparoscope, the 3D high definition laparoscope can clearly show the 3D anatomy structures and the important relationships among different organs. The visual sense of layering is better than the traditional two-dimensional laparoscope. The 3D laparoscope can promptly guarantee the minimally invasive surgery and increase surgical efficiency greatly. So far, there is no report about the application of 3D laparoscope in the pancreatic surgery.
| Conclusion | | |
Today, science and technology are developing in an ever-increasing speed, so are the surgical equipment and technique. The treatment of pancreatic diseases will be based on the cooperation of surgeons and multidisciplinary association for pancreatic disease studies. We should broaden our horizon and be glad at innovation. And we should apply new diagnostic tools and advanced equipment into the clinical work of pancreatic surgery. We must improve prognosis of patients with pancreatic disease through our joint efforts.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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