三维仿真建模技术对腹腔镜辅助直肠癌根治术手术方案的指导作用

Guiding role of three-dimensional simulation modeling technology in laparoscopic-assisted radical resection of rectal cancer

目的:利用三维仿真建模技术于术前对直肠癌患者的结直肠肠管、肿瘤、关键血管等解剖结构进行三维重建、分类及测量,评估所得数据及信息对腹腔镜辅助直肠癌根治术的吻合口张力预判、重要血管变异类型、解剖标志定位等的准确性,以及对手术的指导作用。方法:回顾性分析2019年1月—2021年2月首都医科大学附属北京地坛医院普外科收治的50例腹腔镜辅助直肠癌根治术患者的病历资料,其中男性31例,女性19例,年龄42~83岁,平均年龄(62.72±15.21)岁。以患者术前是否进行三维仿真重建进行分组,将术前行腹盆腔增强CT并进一步进行三维重建的患者作为重建组(n=24),将术前只常规进行腹盆腔增强CT的患者作为对照组(n=26)。对于重建组患者术前利用Mimics软件对患者CT影像资料进行三维仿真建模,针对模型进行术区结直肠及肿瘤长度、盆腔壁刚性结构相关长度、肠系膜下动脉(IMA)距左右髂总动脉分叉点长度、IMA变异类型及占比、左结肠动脉(LCA)距IMA起始部长度、LCA与IMV距离等关键数据进行测量,并与术中所得实际数据进行一致性相关系数(CCC)分析,评估三维仿真建模技术对于手术指导的准确性。采用MedCalc 19.0软件进行统计学分析。结果:重建组模型各径线数据(肠道、盆腔、血管)与术中对应结构测量值,经一致性相关系数CCC评价均大于0.9。预测游离结肠脾曲1例,实际游离结肠脾曲1例,预测准确率100%。重建组IMA变异共分为4型,均经手术验证。重建组手术时间(P=0.011)及各血管定位时间(IMA,P=0.043;LCA,P=0.007;IMV,P=0.034)均较对照组缩短,且术中出血量少(P=0.017)。结论:术前应用三维仿真建模技术有助于术者准确预判术中吻合口张力、IMA变异类型及其相关径线长度,据此可于术前制定精准手术方案指导手术。

Objective Three-dimensional simulation modeling technology was used to conduct threedimensional reconstruction,classification and measurement for the anatomic structures of colorectal canal,tumor and key blood vessels in patients with rectal cancer before operation.And the accuracy of the data and information obtained for the prediction of anastomotic tension,important types of vascular variant,positioning of anatomical landmarks,etc.in laparoscopic-assisted radical resection of rectal cancer,and the guiding effect of operation was evaluated.MethodsThe clinical data of 50 patients with laparoscopic-assisted radical resection of rectal cancer treated in the General Surgery Department,Beijing Ditan Hospital Capital Medical University from January 2019 to February 2021 were analyzed retrospectively,including 31 males and 19 females,aged from 42 to 83 years old,with an average age of(62.72±15.21)years.The patients were divided into two groups according to whether the patients underwent three-dimensional simulation reconstruction before operation.The patients who underwent abdomen pelvic enhancement CT and further three-dimensional reconstruction before surgery were taken as reconstruction group(n=24),and the patients who were only routinely performed abdomen pelvic enhancement CT before operation were taken as control group(n=26).For the patients in the reconstruction group,the CT images were modeled by Mimics software before operation,and the key data such as the length of colorectal and tumor,the correlation length of rigid structure of pelvic wall,the length of inferior mesenteric artery(IMA)from the bifurcation point of left and right arteria iliaca communis,the type and proportion of IMA variation,the length of left colonic artery(LCA)from the beginning of IMA and the distance between LCA and IMV were measured,and the consistency correlation coefficient(CCC)was analyzed with the actual data obtained during operation.And then the accuracy of three-dimensional simulation modeling technology for surgical guidance was evaluated.MedCalc 19.0 software was used for statistical analysis.ResultsIn the reconstruction group,regarding the data of each dimension of the model(intestinal tract,pelvic cavity,blood vessels)and the corresponding structural measurements during the operation,the consistent correlation coefficient(CCC)evaluation was more than O.9.One case was predicted to have free splenic flexure of colon and one case actually had free splenic flexure of colon.The prediction accuracy was 100%.The IMA variants in the reconstruction group were divided into 4 types,all of which were verified by operation.Compared with the control group,the operation time(P=0.O11)and the location time(IMA,P=0.043;LCA,P=0.007;IMV,P=0.034)of each vessel in the reconstruction group were shorter,and the amount of intraoperative blood loss was less(P=0.017).Conclusion The application of threedimensional simulation modeling technology before operation is helpful for the operator to accurately predict the intraoperative anastomotic tension,the type of IMA variation and the related diameter length,based on which the accurate operation plan can be made to guide the operation.